Shocking Article – ACEM accused of systematic prejudice

Today’s Weekend Australian

The Australian College of Emergency Medicine (ACEM) has been accused of systemic racism by more than 30 non-white students, who have revealed their white colleagues are 13 times more likely to be admitted as specialist emergency doctors.

The students have lodged a highly detailed 34-page complaint with the college showing that, of 204 candid­ates participating in the program for the second half of last year, non-white candidates — who make up more than a quarter of all enrolments — had a clinical exam pass rate of just 6.8 per cent.

That compared with a pass rate of 88 per cent for their white classmates. The clinical exam is the last hurdle for doctors attempting to become emergency specialists and exams are taken twice a year.

The group of 33 non-white stud­ents who have filed the complaint say the vast disparity in results­ cannot be explained by poorer skills or language issues, given they have worked alongside their white counterparts for years in hospitals and shared the same training. The students were all fluent­ in English, and many spoke English as their first language.

“That the college would pass less than 10 per cent of the non-caucasian cohort, deeming the rest unfit to be emergency medicine specialists, while passing the vast majority of caucasian candidates is embarrassing to the college,” write the students. “It is far out of step with community standards as well as being clearly … discrim­in­atory.”

College spokesman Fin Bird said: “We can’t comment on the specifics of any case … to respec­t the integrity of the process and confidentiality of the applic­ants.’’

The group of students — who have requested confidentiality for fear of career repercussions — want the college to “statistically modify” last year’s clinical exam results to “remove the clear elemen­t of racial bias from them”.

The students have also filed the complains to the Australian Medical Council, which oversees grants and accreditation of the ACEM and all other specialist medical training colleges. Council chief executive Ian Frank told The Weekend Australian his organisation was aware of the complaint but was seeking more details before­ it could comment further.

In 2015, the Australian Medical Council introduced new policy regardi­ng assessment and accreditation standards and this year, for the first time, the college will have its accreditation practices reviewed under the new standards.

The students said while the college did not publish student results, they had been in contact with 59 non-white students from last year and found just four had passed the clinical exam. One of those students who spoke with The Weekend Australian said he had repeatedly failed the exam and the “racial discrim­in­ation” had a demoralising effect on him and many non-white stud­ents.

“We are looked down on by our fellow colleagues and consultants after repeated failures as if we are not trustworthy,” he said. “This exam had made me lose the happiness I had working in emergency medicine.”

The students listed pass rates for all hospitals where ACEM stud­ents worked. At Newcastle’s John Hunter Hospital all four white candidates passed, but all five non-white candidates failed. At Canberra Hospital, one of the two white candidates passed while all three non-white candidates failed; and at Brisbane’s Prince Charles Hospital all four white candidates passed while the only two non-white candidates failed.

Comments and Ideas on this Pressing Issue

Feedback on this article is very divisive on twitter already:

This is a really sad situation (as reflected by the on-going list of comments below).

The notion of issues with ethnic imbalance in exam success was reported 10 years ago in the UK MRCP exam system (and 20 years ago in the UK undergraduate medical exam system). The data on pass rates is publicly available and it has been documented that overseas doctor suffer prejudice when integrating in Western medical systems.

This ‘LINK‘ takes us the the MRCP gender and ethnicity equality report from 2015, a relatively similar high stakes post graduate medical exam in the UK.

The following graph from this report shows the pass marks for the UK MRCP clinical examination:

This graph appears to show that your chance of passing is 989/2291 (43%) if you are a non-white overseas doctor compared to 789/920 (85%) for white locally trained doctors. Therefore, a gap in performance based on ethnicity appears to be widespread – not unique Australasian Emergency Medicine. In summary, it appears pass rates are significantly lower for international medical graduates (IMG) in many medical exams.

Furthermore, our FOAMed friend Dr Simon Carley (@EMManchester) raised this issue at the St Emlyn’s blog at the end of last year. He quoted General Medical Council (GMC) data suggesting that not only to overseas trained doctors have lower pass rates, but so do locally trained candidates from an ethnic minority background.

From these international trends (which are clearly not unique to the challenging ACEM exam) – I think we can conclude at least a few things about the situation in 2017:

The issue of why the international medical graduate’s pass rate is so low is likely much more complicated than ‘inherent racism’

Most local Directors of Emergency Medicine Training (DEMTs) can accurately predict based on rehearsal performance who is going to pass and fail the ACEM exam

This could suggest a inherent cognitive bias by FACEMs towards what is deemed a ‘correct exam performance’. Alternatively, this could suggest there is no ‘systemic’ deliberate attempt to fail any one group of candidates.

Other contentious factors may be at play to drop the pass rates – this may include IMG assessments in their baseline medical education (exposure to OSCEs at under graduate level), approach to study (rote learning)… There may be a number of other factors which are as yet not recognised which lead to certain candidates not translating their knowledge into an exam success.

The comments section (below) reflects a range of views on how much racial discrimination is a factor in college examination

ACEM like the the UK RCPneed to be transparent in its reporting and be proactive in attempts to improve all candidates performance in examinations

Academic Work

We believe, her work is worth a look as she is one of the top reporters on the subject of why ethnic minorities under-perform in both undergraduate and postgraduate exams:

Woolf et al (BMJ META-ANALYSIS (2011)) – ‘Ethnic differences in attainment seem to be a consistent feature of medical education in the UK, being present across medical schools, exam types, and undergraduate and postgraduate assessments, and have persisted for at least the past three decades. They cannot be dismissed as atypical or local problems. This is an uncomfortable finding, with good reason. While exam performance is by no means the only marker of good performance as a doctor or medical student, the fact remains that without passing finals, medical students cannot become doctors, and without passing postgraduate exams, it is much harder for doctors to progress in a medical career. That exam results vary by ethnicity is therefore extremely important and requires attention. Although ethnicity is clearly related to exam performance, what is not clear is why that might be‘……….. ‘Ethnic differences in academic performance are widespread across different medical schools, different types of exam, and in undergraduates and postgraduates. They have persisted for many years and cannot be dismissed as atypical or local problems. We need to recognise this as an issue that probably affects all of UK medical and higher education. More detailed information to track the problem as well as further research into its causes is required. Such actions are necessary to ensure a fair and just method of training and of assessing current and future doctors.’

However, I do take issue with the fact that ‘non-white’ is being equated with international medical graduate. The article does not specify whether the ‘non-white’ doctors were IMGs or not, and in fact mentions specifically that a number had English as their first language. And on the subject of IMGs, it must be remembered that a significant proportion (and in many EDs the majority) are from the UK.

As Dr Carley points out in his article, people from ethnic backgrounds have lower pass rates whether or not they are internationally trained. And even if it assumed that all the ‘non-white’ doctors in the article are IMGs from non-English speaking backgrounds, the pass rate of 6.8% is shockingly low and much lower than that of the IMGs in the MRCP exams.

I am a ‘non-white’ doctor and I have lived in Australia my whole life and English is my first language. Yet I am continuously asked by my patients if I trained overseas and how long I’ve been in the country. Thankfully I’ve only been told to ‘learn to speak English’ a few times, but each has been disheartening and upsetting. A quick perusal of the Facebook and Twitter comments on this article makes it clear that there is significant distrust and suspicion of non-Caucasian doctors who are assumed to be poorly trained and dangerous.

And if this attitude exists in the general population, who is to say that it does not exist amongst the examiners? Being a FACEM does not make one immune to such biases. This is not a problem isolated to emergency medicine, but ACEM’s silence on this issue (which has been well known amongst trainees since the introduction of the new format exam) has been deafening.

As you say, the College needs to be transparent and proactive in its response.

Example posted for MRCP UK exams is completely irrelevant here. Any Tom, Dick or Harry from Asia, Africa or even Antarctica can pay and sit those exams without ever setting foot in UK healthcare system.

Here we are talking about Advanced ACEM Trainees with 7-10 years of supervised training and rigorous in training assessments, hence a totally different situation.

Hi Sam. Thanks for your contribution to the discussion. Point taken regarding the difference between FACEM and MRCP(UK). However, I disagree that is “completely irrelevant”. We used PACES as an ‘equivalent’ as you have to pass two written knowledge exams (MRCP part 1 and 2) in order to sit it. Additionally, I also believe you have to show you are working in clinical medicine and are at least 4 years post graduate.

In the MRCP PACES exam (which I sat in 2008) you had to demonstrate many of the communication competencies that are at the forefront of the ACEM OSCE.

If you take another example of the FRCEM exam in the UK a similar pattern emerges – younger, female candidates doing well – older male candidates doing worse in terms of passing. Ethnicity appears to be an important additional independent factor in terms of the chance of passing.

You state that ACEM training is rigourous. I do not disagree that the job of being an ED Registrar certainly is very challenging. The question of whether feedback from WBA performance is marked at the level of the final OSCE is open for debate though in my opinion…

Isn’t it nostalgic to remember the recent past, when Emergency Medicine graduation was producing the most multicultural output of all specialties? That balanced well in producing cosmopolitan, specialised doctors to address the diverse needs of today’s extensive, multicultural communities that we all call home. Then, the forward thinking mindset plummets over just 3 short years. It now is deemed that non-Caucasian trainees are funelled through with a 1 in 13 chance of passing compared to their Caucasian counterparts! Why become so capricious in deciding who graduates? Who is responsible for commanding these barbaric procedures and destroying the hard earned careers of so many capable colleagues of ours? Why ruin the morale of this society? How would the community react if an exam produced a 90% failure rate for all the women that sat the exam?

Lets first correct one thing.these are not students these are senior emergency doctors who has been running the show in busy emergency departments and most time they in charge of major emergency departments all over Australia. And to suprise you even.they do speak clear and fluent English otherwise they wont be able to pass all previous traing requirements and exams.

No offense as a non Caucasian doctor or person. We work 10x harder inorder to proof ourselves and we do that with passion.
Most of those non Caucasian have thier directors telling them repeatedly “you should pass but I’m sorry you did not and not sure”

Most work based assessmemt are passed by those candidates and still that doesn’t mean anything as behind the scene there is a big monopoly ang tight control by the college berocrates.

Sat the exam 2 x and smart enough. I got the message.if you don’t talk and behave as a Caucasian doctor then sorry mate try again and again forever till you sick of the exams or till copy what the examiners and the college wanted which essentially is … no body knows what!!!!

The exam is illegal in the sense that it does not provid a clear picture of what is expected and also even the most senior examiners have no idea how the candidates are marked or they just want to keep that secret. Who knows.

Those examiners have been doing this job for 20 years or more and they control the pass rate to their taste.also they feel threatened if too many successful people suddenly trying to take their jobs .all envy at the end

You wait for college feedbacks. Such a waste of time as those feedbacks are essentially not telling you anything (thanks for the college to provide detailed feedbacks to help thier trainees….
such a joke. Please don’t bother.
College replies are generic copy and paste to any request.

The racism in the college of emergency medicine is tip of the iceberg. This is rampant in the hospitals and the medical world in Australia, thanks to a few brave bunch of desperate emergency trainee doctors, this has come out in the open.

The proof lies in the pudding. The racism is not actually racism but a weeding out process , if one really connects the dots and realises what is happening. A decade back there was shortage of doctors in Australia, in specialities, rural, Gp etc. Thanks to the famous professor in Melbourne,( not to be named) his words were taken as gospel and government did not increase the number of medical graduate in the universities , as according to this professor, the Australia did not need extra doctors. He hardly said that and just few years later there were shortages. Government realised the folly of believing this person and scrambled to open doors for foreign doctors. The flood gates were open and foreign doctors flooded Australia.

Then the process started of increasing the number of graduates in the medical universities. After many years, now the government , or at least some influential authorities high above feels now it is time to tighten the screws of inflow of foreign doctors as the numbers of graduates coming from the universities is near sufficient. So what to do with the flooded foreign doctors? Then the clever plan was devised. If they have become specialists , in a field, instruments are devised to keep a check that they stay put in that place and not go higher. What about the others? because they are competing with the local graduates who are now in the system. They have to be weeded out to pave way for local to squeeze in. This is when a group of influential “high above” hatched the changes in the education system!! In specialities.

What did they plan? The thought process is this.The structure of changes should be in such a way that 1. They can weed out these doctors knowing their weakness 2. Do it such a way that no legal hurdles occur. So – came the sweeping changes- Short answer question patterns and work based assessments and non transparent OSCE exams. Every one who had not seen through what is happening inside will oppose saying that this is just a nut talking about conspiracy of some sort. But one really has to pay attention to understand how the weeding out process occurs, or as the IMGs now cry out loud – racism occurs. It is not really about racism, dear IMG. Only if you open your eyes and see.

The IMGs have come from non English speaking background, and different training process of medical education. So how can they be trapped and weeded out?
1. In English- The barrier has been increased by the government to get the Permanent residency by asking all these foreign doctors to get an IELTS score of 7 in all , not as aggregate. 9 is the highest level one can achieve. Many candidates have not been able to get through this first hurdle.
2. If they have passed their then second hurdle is AMC exam. This says it is an exam at the level of final year medical student in Australia. Really? Let us accept that it is . But how come many candidate fail? . Simple reason is there is no standardisation process of AMC clinical exam and pass fail rate is based upon how many “sympathisers (“ examiners) were present in the exam. Unfortunately many examiners in AMC turned out to be IMGS and local whites, who have soft corner for foreign graduates, and have let the gates open to many foreign graduates passing the exam. They have entered various colleges as trainees and now,they have to be weeded.
3. Now comes the devious instruments to create barriers in getting these IMGS get through the colleges, and weed them out.a)Work based assessments- these are instruments the colleges use to pass the candidates. Outwardly it looks as genuine and instruments of quality improvement. But it is a weapon that these colleges wield, that the graduates are kept a check. These tests are done by superiors and hence one has to be at the mercy of the attached organisation and be at the good books of superiors always. The bar for passing these for IMGS is high that he has to really really work hard to get through. Whereas the bar for passing local grads is so low that unless local whites really screw themselves up, they will not fail. The assessments are based not on the knowledge alone, but other “ qualities” where one really does not have a scale to quantify. It is done as gestalt but the supervisors. One easy way to fail these candidates- labelling them as poor in COMMUNICATION, as it is difficult to argue upon- remember IMGS come from Non English speaking background. And yes, they cannot talk like local whites. also Slang, accent and thinking , are all different.
4. Short answer questions exam- sounds easy to pas , right. But not, If one can really listen to what the “examiners” say they want to see in the answers. The answers for the fellowship exam requires only few words or phrases for each question. But they require consultant level answers. Sounds good. Reasonable. And quality !!. BUT, there lies the trick- How can a three word tell you that you are a consultant or not a consultant level candidate? Trick is in vocabulary, which IMGS lack and locals pass easily. So it is not racism, sir, but a barrier created by the intellectuals and a weeding out process. The sons and daughters of these IMGS have passed these exams-the reason is that they have the local vocabulary and training and they know the tricks. So who is right and who is wrong.? Difficult to say
5. How do the examiners identify whether the candidate is local or foreign grad? By the handwriting. !! This is not something to be taken lightly. It was told to one of the candidate that he should change his handwriting as it shows that he is from different background- for example cursive writing, and calligraphy style writing etc. Really? It is said by one of the examiners and hence one can see how deep the weeding out process deep-rooted in the system
6. OSCE- objective structured clinical exam- nice words, quality sounding. Only that the college has got no structured way of assessing the candidate. It is secretively done, and only the final marks are revealed. rest assured is the gestalt and opinion of the examiners. Once again if a white candidate enters the exam station, the bar is really low of passing , whereas the IMG, have to really struggle hard to even pass barely, as in the minds of these examiners the bar is really high..
7. So , even if all these hurdles crossed and he comes out, then comes the local institutional selection for posts. It is difficult to get into a group of “ elite “ men in the colleges, unless you agree to start at a lowly level , not threatening the hierarchy. Many of them have decided to join and keep their mouths shut as “ living’ has become a priority- family and mortgage to take care. What about the rest of IMG who had joined the top core ,as examiners and administrators? They have been made to think that they are serving the bigger cause and made to think like whites and act like whites. Given the positions, they cannot and do not want to be thrown down and hence become one of the persons involved in weeding out these IMGS.
8. The local whites, who had been in the higher posts, who has seen through these devious instruments in play, have revolted, for correctness and fairness, but most of them miserably failed and they left the system.
Hence it is high time, IF and only if Australia wants to show that they are non racists and fair, to come out in open and accept that these has been going on and promise to correct and come out with instruments to be transparent and genuine. One can expect denial from college of Emergency medicine, about racism, and they should, otherwise it will seem that they are accepting it. It is a catch 22 situation. If they accept they are leaving room for litigation, if they don’t , they will be incacerated by the IMGS. But deeply, this does not rest with College of emergency medicine alone, it goes to GP training, and other colleges too. AMC has been instrumental in bringing out the educational changes in colleges. Are they involved in the weeding out process? Who can tell?

A couple of questions/comments for Mustafa having read his post as a Caucasian, Scottish FACEM

What is a Caucasian Accent?!

Secondly, do you really think Mustafa that certain ethnicities works 10 x harder than others? Wow.
Hyperbole aside, this will be pretty offensive to many.

Finally, if you think ED registrars run the show out of hours, you’d be right to some degree… registrars do ‘run’ the night shift… and see the majority of patients in the ED (under supervision), but the progression of an Emergency Medicine and the overall health system needs hard working FACEMs behind the scene doing the governance. I for one spend as much time teaching, leading when required, going to meetings, answering complaints, monotonously tacking administrators etc. as I do “on the floor”

Dear Andrew –
I do want to clarify want point – for sure We all mostly work hard as emergency Registrars- What I mean by working 10 x harder is mainly initial struggle to integrate in to the Aus Health system and then try to perform at your best in terms to match your “Caucasian ” colleagues in particular communication ( Which is for sure a natural thing for Caucasian Candidates).So in no way I am saying that my Caucasian Colleagues are not hard working , that is for sure not a true statement .

The examiners used to blame communication skills , and now ” Knowledge ” and Who knows what else later , so I ended up seeing a Communication consultant ,trying to improve my chances of passing the exam as the college advice , after 10 min talking to me she said” I really don’t know why you wanted to see me, your English is perfect and you don’t need any coaching !!!”

I also think your post over simplifies our diversity and ethnicity.
– Emergency doctors are diverse in attitude, aptitude, personality, age, gender, sexuality, culture, education and our various shades of skin tone. Likewise the FACEMs I work with are diverse in all these characteristics, and all for the better

My problem with the examination is it allows for a lot of subjectivity (or you could call it examiner bias – intended or unintended- it does not really matter)- which is a problem is you are going to use the borderline regression method of marking which the current examination does.
An objective examination to me is one which implies that should a different examiner mark you they are likely to reproduce thesame mark as the previous one. Its very unlikely with this current examination which although it has ‘tick boxes’ – they are not quantified how much each of those actually weighs. Simply put – there is no quantifiable, reproducible marks for what you have actually said. It is up to the examiner by some obscure method to then give you a mark they feel you deserve. It would be disingeunous to suggest you have not heard most examiners state they go or can have a feel of the candidate and thats how they mark the candidate. Some might suggest that the lack of a stringent quantifiable tick box system presents an ‘opportunity’ for bias.
For example – I have seen a report where a candidate has been given 333 for a surge management question. The reason given for this score was the candidate was going back and forth. While globally it might make sense that a smoother candidate may get more marks for example in communication – this should not impact his overal score in the medical expertise section because he has said the things on the tick box. Thats the spirit of the borderline regression method. Thats the objectivity part of it. Whats most likely happening is examiners are not doing this and there is some evidence to support this. They look at the flow – and its possible that IMGs then get marked down for ‘stummering’ which in the Western world suggests hesitancy or as ‘Bob Dunn’ suggested on his leaked mail to the DEMT group lack of confidence.
The result is perhaps predictable in that it becomes a double whammy for the poor IMG
You get marked down for a station that you have done well just because there is no stric adeherence to the spirit of objectivity
And a similar perfomance by a non IMG is viewed similarly.
Sadly it appeasrs when you do well – you can only get a 555, and when a non IMG does well its not unheard of to get 777.
There is an interesting marking style that has come up from the last examination. The double station that had the TCA overdose will be interesting how it was marked as other stations will reveal.
The college needs to take concerns of everyone seriosuly
I am sure if there were 90% of caucasian candidates that were failing the examination – the college would have investigated this a long time ago. The fact they have not is unfortunate and a further example of lack of concern and perhaps a feeling that IMGs deserve to fail and that this does not really impact on their lives

this is exactly the problem
you do very well in the station you get 555, you don’t do well (because you are not competent) you get 2s and 1s which will make it impossible to pass.
others do well straight 777, do bad (because they are stressed) they get 4s and 5s.

Hi Andrew
Thanks for allowing the discussion.
Despite repeated failures i for a minute don’t believe that the racism is the cause for our failures.
I also don’t believe that only 10% of us are clever enough to pass this exam.
I think there’s an unconscious bias against non English speaking candidates.
How College tackles that bias is the challenge.

Hi Andrew,
Thanks for starting the discussion. It is one that needs to be had, however uncomfortable it is for some of us to hear.
The stats, if true do indicate a “bias”. Is it an unconcious bias on the part of the examiners? Perhaps.

I don’t think there is blatant racism in the college, but I don’t know how the examiners can be sure that an unconcious bias,based on appearance, does not exist, as it is put in the article , agaisnt ” non- white” candidates.

As a FACEM who is a local graduate, English being the first language of both myself and my parents, but whose appearance is distinctly “non-white”, I would be interested to know the pass rates of local ” non-whites” as compared to their “white” counterparts.

Anecdotally, both in the areas of exams and day to day work, I can say that the playing field is indeed not level.

ps: I am quite sure that “perfect english” is not a requirement for someone to pass the FACEM exam. I seem to understand Mustafa pretty well, and I am sure that most of you do , and so will most patients.

Hi Andrew,
You can argue both ways still cows come home.Allegation has been brought not for the first time.ACEM should request the AMC to conduct an independent commission to investigate the allegation.The commission should investigate.The members should be all races,all specialities(including non medical),govt , opposition members plus patient representatives .If ACEM has nothing to fear then should encourage.Racial discrimination is criminal offence.Australian law does not tolerate it.
Sam

Hi Guys,
Good discussion around osce examination. If the numbers mentioned for IMGs/Caucasian non pass rate is correct or near correct then its a serious concern. We can call it by various names for example racism, weeding out process, bias etc but end result expected by college /exam committee is same thats is low pass rate for IMGs/non Caucasian.College has to wake up and correct the process to prove themself instead of putting the whole blame on trainees.Definately it cant be such a huge variation in pass rate.
Btw has anybody has answer why college needed this new exam pattern? Do they think previously passed FACEMs(few current examiners) are not competent enough or Is there any other motive?

I was fortunate enough to attain the fellowship without facing currently alleged issues long before the “influx” of “non-white” trainees into the training program.

Needless to say that this “influx” was a demand and supply issue at that time. ACEM freely allowed it to happen perhaps to meet the demand, popularise emergency medicine or for other reasons.

I do not think there is institutional racism ingrained within ACEM. My understanding is that there are a number of policies on diversity. I am not going to say that there are no diversity issues within ACEM.

My experience and opinion is that if there are any discriminatory practices those things happen at a lower level, most likely at FACEM level – in their various capacities as examiner, supervisor, director or any other powerful position.

When I did the fellowship I didn’t feel discrimination, especially when others got to know me. However, things have changed now – the whole world seems to be going in a different direction.

Unconscious bias is a well known phenomenon especially in human resources and they describe this with a different vocabulary. I do not want to be too simplistic but this is a known reason why a director selects “someone like him/her” as a deputy or as another FACEM to work in his/her ED. For the same reason a candidate who has come from a background similar to the interview board members gets higher rating in an interview than a candidate who is from even a slightly different background but with similar or even higher level of experience and qualifications. Unfortunately, these are very familiar scenarios for most of us who are from a minority. Most minorities silently suffer without choosing to hit their heads against the wall.

One can argue that these biases could well happen especially during clinical exams where there are loose rules of marking and there is no blindness towards the candidate.

I consider the current allegations as part of a conglomerate of undesirable things happening in Australasian emergency medicine. Although some of these are under the control of ACEM but mostly they are not.

I have given two of my observations, I understand these are anecdotal, but I am sure you have seen these somewhere. I apologise some of these are not what we want to hear.

1. Good residents and registrars from “non-white” backgrounds are more likely to be marked down in assessment meetings by FACEMs. At the same time I have heard these words more than once during my lifetime about “non-white” residents/registrars – “…….guy, he is good” (in other words, he has come from a particular part of the world, therefore he must be good).

2. Possible bias in FACEM recruitment and selection processes. For an example in Brisbane, there are not more than 1 or 2 “non-white” FACEMs working in the two tertiary EDs. On the other hand, there are lots of “non-white” FACEMs work in hospitals in the certain suburbs that are often described as low socio-economic. I am not sure if this is the case in other capital cities.

Are we proud to say that these are non-discriminatory, non-bias practices?

I hope the ACEM and MBA will fully investigate the current allegations. Due process and natural justice should prevail irrespective of how much it may become uncomfortable for some.

Facems of non Caucasian background sit 10 interviews before they were given the job.while I know a white FACEm applied to a major tertiary hospital in Sydney (while he was overseas holidaying)and was given the job on the spot.

I just detected a typo in my post. For clarity it should read as the following…

1. Good residents and registrars from “non-white” backgrounds are more likely to be marked down in assessment meetings by FACEMs. At the same time I have heard these words more than once during my lifetime about “white” residents/registrars – “…….guy, he is good” (in other words, he has come from a particular part of the world, therefore he must be good).

I personally do not believe that Racism is a cause for these exam results.
I am just surprised why 9-10% of non white candidates pass as compared to 88% of white candidates.
If this is really the case then certainly there is something wrong with the college examination.

As far as Mustafa’s English is concerned, I can understand it perfectly, so can his colleagues and his patients.I can say that as someone who has had the pleasure of working with him over the years.
I am just astonished that from a discussion about “a topic” it dropped into a discussion of how good or bad or “not perfect” his English is.

Maybe this is exactly what happens in an OSCE room , as well, where the discussion about Medical Expertise gets transformed into a discussion about assessing competence in English and some people think that they are sitting here to assess an IELTS candidate.

Ouch and touched!!! how this discussion took a fair chunk on someones English literacy, wow wow wow…

Some one very level headed as Andrew, who actually as a good Samaritan want to engage in this topic. Even he has subconsciously made a statement about some ones language. Now think about all other examiners who are not that generous as Andrew.

I am not personally targeting at Andrew, in fact I really respect him for bringing this topic for a wider discussion. However I want to bring out the salient point about our subconscious bias that we all are inherently subject to. Denying “favouritism” as it does not exist is a blatant lie and or not clearly understanding our self as humans. This will only help us to convince us as we are better personals. However being aware of it as Favouritism does exist and working around would be the better way to reduce bias. When I say “working around” it is not only for the college, even for us as the minority communities we should know it does exist and have to work around this.

Once upon a time Slavery was legal too but we got this far from it now …

Thank you Andrew for facilitating this contentious and divisive debate on your excellent website. It is definitely a discussion that is long overdue.

First of all allow me to declare my bias and conflict of interest. I am a South East Asian born, European trained, non-Caucasian doctor who decided to migrate to Australia to pursue a career in Emergency Medicine.

I have sat for the 2015.2 and 2016.1 (1) OSCE sitting and failed it on both those occasions. I have therefore seen this examination evolve while preparing for it.

This issue after being made public, has in some instances made the complainants/appellants seem jaded, conspiratorial and on occasion just angry. The reason for this is simple. It is because we are.

The question remains; is the Fellowship Examination an accurate, reliable and fair tool to determine if a registrar is functioning at a FACEM level . In my humble opinion I think the examination process has failed spectacularly with regards to this.

During the fist sitting of the new format in 2015.1, the college provided us with a poorly conceived and executed examination. There was an overwhelming backlash from the vast majority and the college’s response to this issue was to pass a large proportion of the candidates, hence resulting in one of the highest pass rates for a written examination in years. The disapproval then died down as everybody passed and this issue was swept under the carpet. The concern with this course of action is, has the college passed candidates that are not up to scratch? Has the college been taken to task or asked to answer for their actions? I doubt this.

The second issue with regards to the OSCE examinations is the issues of cheating during the OSCEs. As we all are aware, the stations during the OSCEs were the same from day one through to day six.This raised the question of candidates disclosing the contents of these stations to candidates on later dates. This was reflected in the improvement in pass rates from day one to day six that the college chose not to release. Their response to the problem was to hire a statistician and a legal representative before releasing a generic letter expressing their concern to the trainers and conduct an internal investigation behind closed doors. The result? Inadequate evidence to determine if cheating occurred and statistical black magic to determine who makes the cut. In any event, no open disclosure to the chain of events that led to this or the statistical calculations that were performed .

Now the latest issue with regards to this examination is the allegation of bias to a minority group. Through sheer determination and resolve candidates have compiled their own data and submitted it to the college . What we require is open disclosure of the results and transparency that the college has failed in providing to us. We need this for peace of mind and to answer so many qustions we have . I am certain the college will again in this instance deny us this.

Due to all these factors concerning the exams, how are we as trainees meant to feel a sense of belief and trust towards ACEM. All we have as a group is doubt, anger and regret. The college has failed us. It is not all inclusive and diverse. How are we meant to come to this conclusion based on their pass actions?

The repercussions of this has left me with a huge financial debt ( due to time off in preparation for the exam), a strained and fractious family relationship with my children and partner and an overwhelming sense of self doubt in my abilities as an Emergency Doctor. I am sure I am not the only one who has had to endure such turmoil in my personal life due to the examination.

I hope on this occasion, ACEM does the right thing and allow our voices be heard.

It’s good to see someone has done a study (Dr K Woolf) out there to prove to me that if you are of ethnic background then your brain does not work as well as if you are a Caucasian hence you are less likely to pass an exam. If only someone had told me this before I spent 5 yrs passing my FACEM exam it would have been a consolation and I may even have not dared to think my abilities were equal to my learned caucasian colleagues. I would have returned to my role as a filler of shifts and cover for sick relief consultant cover when the real FACEMs are away, it’s ok then to run the department.
In the 5 yrs it took to pass the exam- I missed out on time with my kids, my depression got worse and I began doubting my self. I could see colleagues who I taught get through but due to my defective DNA I remained incapable of passing.
Instead of standing up to this injustice, I see people using words to condone what is wrong.
It may be true that if you are of colour then you are not up to it “Boy”. It truly is a white world.

Hi Andrew
Thanks for editing your initial comment about Mustafa s English to a more respectful and considered one. It does however , make the comments that follow from some of us seem “over sensitive ” and “over the top “( including Naveed’s) when we have questioned or called you out on your initial statement . Perhaps a simple ” I shouldn’t have said that the way I did and this is what I meant to say …..” might have been the better option .
For those that have only just started followed this thread it might make more sense why some of us were upset by the ” perfect English ” comment .
Just a suggestion …

I (slightly) diluted my comment after consideration (and have now flagged it as edited).

I was pretty upset in my reading of Mustafa’s attitude towards those who have passed the exam (including me) but recognise that the comment was poorly timed, unprofessional and insensitive in the context of this thread and topic. As the moderator of the site I should be be quick to listen and slow to speak.

I recognise that this is an emotive issue.

I stick by decision to post this article for public discussion and the brief commentary posted below the article…

To clarify, my assertion is that there is no ‘conspiracy’ or systematic racism but that there is a significant problem in the college assessment process. Therefore, there should be transparent reporting by ACEM and an investigation into the current situation. The data that is presented by the complainants lodging the quoted report should be fully checked and in future the college should formally monitor the situation with independent arbitration and public access to reports.

We can name it as whatever we want, but it is true that certain people are being discriminated in this exam. Why does someone “have to behave ” like certain stereotyped personality to pass the exam?
When ACEM says it’s proud of its diverse culture and then turns back and says you won’t pass unless you behave like a Caucasian , then it’s a farce.
Most of the examiners and the committee members who make the rules and pretend be safeguarding the community of FACEMs are old and didn’t grow up in a multicultural environment. They are still stuck in their old ways. These days I see people of multiple cultures coming to the emergency department and not all of them understand the language and the mannerisms that the ACEM wants.
All they need is a competent doctor who can make them well or atleast make them feel better that they are in a safe place.
ACEM and it’s committees have to understand the multicultural aspect of current Australian population and stop pretending only white Australians are being treated in the emergency departments.

Declaration: I am a non-Caucasian FACEM. English is my first language.

The statistics I would like to see are how many candidates have failed the osce multiple times, having passed the inaugural written exam (which had the 88% pass rate). Could there be a backlog of these candidates who are stuck at the last hurdle? Possible.

I personally believe that by the time any candidate sits the osce, disadvantages such as nuances in communication should have been identified and ironed out. In the case of IMGs, special attention should be offered early in advanced training so that language will not be a reason for failing.

Without going into detail, I have been a confederate in the osce for different examiner pairs, and have not witnessed discrimination of any sort thus far. Some of the best performances have been by non-Caucasians who have accents suggestive of English not being their first language.

I understand how upsetting it must be to fail this exam after all the hard preparation. But from what I’ve seen, those who succeed after failing seem to have more insight into their own shortcomings and focus on correcting these, rather than externalising blame and reaching for the race card.

Finally, I think the comment on Mustafa’s English was fair, just poorly timed as Andrew has admitted. Mustafa did mention a language coach telling him he had ‘perfect English’ after a 10 minute assessment, yet in his prior long post there were several grammatical errors, spelling errors, as well as an exaggeration of ED reg responsibility as ‘running the show.’ I’d imagine his English is easy to understand and his vocabulary wide, but ‘perfect’ wouldn’t be the word to describe his English.

We are not merely externalising blame. I firmly believe our grievances are fair . The college has left us in complete bewilderment on why we have been unsuccessful . The previous feedback provided to us on our failing performances have been negligible . The previous issues regarding cheating have not been disclosed fully . Is it wrong if we as a group find through our own observation that there may be a glaring discrepancy and demand answers ? Is it unfair that we demand complete transparency? If there is a true discrepancy , is it not the responsibility of ACEM to allow a thorough evaluation of a potentially flawed system and take steps as a mandated body to fix it ?

PS : if it’s true that some of the best candidates are non-Caucasian , why is it that we almost never see a non-Caucasian win the Buchanan Prize .

I agree that as a group with common characteristics of being ‘non-caucasian, being IMG, or having English as a second language etc,’ it is reasonable to request an investigation to see if these are causative factors for failing. But I would suggest these factors are confounders. Labelling the assessment process, or examiners as ‘racist’ is too simplistic, when the failing factors in IMG groups are likely very complex and efforts would be better invested in correcting them during advanced training than questioning the assessment process. Granted, that the fine detail would be found through evaluating the examination process. I would guess that caucasian doctors fail the exam for the same reasons that non caucasians do, and that all failing candidates work on their understanding and delivery of the curriculum domains.

By the way, in each osce station there are two examiners who mark independently from each other. The AMC centre has webcams on the ceilings, through which the examiners are supervised. Furthermore, senior examiners randomly enter the stations to ensure fair marking. There are 12 of the seven minute stations and 3 of the double length stations now. A non caucasian candidate would need to be discriminated against in a significant proportion of the stations to fail the exam. Then the who discriminatory process would need to happen again and again for the candidate to keep failing.

Re: Buchanan prize winners. I have known or met several of the winners, whom have been exceptional candidates and impossible for the vast majority of candidates, including caucasian candidates to compete with. Let me pose the counter argument to you; If the college is racist, why are there so many non caucasian FACEMs?

My opinion mirrors a lot of what has already been said above. We need emergency department doctors from a range of cultural backgrounds as our patients come from everywhere (how many times have we gone looking for that non-white doctor to help with language interpretation?)

I agree the exam and assessment process is flawed but to state that it is due to racism is going a bit too far. The fact that there are 16 stations with all different examiners surely should reduce this so called ‘racism’?

The OSCE exam is a huge performance act and does not necessarily reflect what happens on the floor – everyone complains because you cannot break bad news in 7min to a family you have just met. But it is just a ‘game’ that you need to play along with and rehearse over and over until you get it right. Fundamentally, the OSCE is a formal hurdle to get through and the style of exam naturally biases certain people (as does any other style of exam) – in particular to the IMGs who have not been exposed to this format routinely it may be viewed as a disadvantage.

What I see as being the problem is
– people can do years if not decades in the training program and to expect them to fix bad habits right at the end is impossible. WBAs and ITAs are introduced as a system to flag people early and yet there is no standardisation amongst FACEMs filling those out. Trainees will go to ones that are lenient to be ‘signed off’
– the exam itself does not offer transparency. Why is it that we all get the scores and comments after trial exams and yet nil feedback post the real thing?

If candidates fail they should get detailed feedback as to avoid the same mistake and also redirect practice. It doesn’t mean changing your accent to be ‘more white’ but certainly changing the speed, tone etc can improve clarity especially in a high stress situation such as resuscitation.

Having said that, those that have passed should not be left to feel that it wasn’t due to their own merit – which is what I think Andrew is trying to suggest.

@KN I do not doubt that you and others feel the OSCE is “just a ‘game'”. I question the validity of using such a game that “does not necessarily reflect what happens on the floor” to assess how well doctors will perform in consultant roles. 7 minutes is not a long time to establish rapport and perhaps it is this artificially compressed time scale that magnifies the subjective aspect of assessment and enables unconscious biases to be amplified.

I think the IMG candidates have been exposed to this format of examination. Consider the people attending courses for their OSCE preparation, the study groups they must form and attend. I disagree that they are disadvantaged because they have not encountered the OSCE scenario.

I do agree that there are issues with the WBA system, that the exam system should offer more transparency and that failing candidates should get detailed feedback so they can improve. The current exam feedback is woeful.

I also strongly feel that the College should constantly evaluate its feedback, investigate and implement appropriate changes in a timely fashion so as to avoid the current situation and similar situations in the future.

Thanks Andrew for facilitating this discussion. Perhaps this discussion is turning out to be more divisive than it needs to be . It is also very interesting to note different perspectives & I could not help share my point of view. Despite the camouflage of words & jargons used, it is very easy to see where every individual commentator stands with regards to the issue & I make no attempts to hide my bias.
I am a coloured trainee and failed the OSCE for the second time recently not because of a racial bias but because of my own short comings . I have prepared extensively with a lot of other candidates ( mostly on Skype) & I know some of them who don’t deserve to fail. I refuse to believe there is a systematic prejudice but then, I can neither explain why certain deserving candidates have failed 3 or 4 times. Whilst I lack the courage & conviction to stand up for my colleagues , I personally don’t feel wronged. I don’t personally approve of using the race card but then neither did I go to the police when I faced racial attack in a train years ago. Putting myself in their shoes, perhaps that was the only way to grab attention and people who are very critical of these trainees need to understand the reason behind it. Having said that , we have been extensively discussing this issue for over a year now , since 2015.2 results & there is a genuine perception amongst coloured trainees that they are being discriminated . These perceptions are reinforced by statistics . These are augmented by some of the comments made by DEMTs & examiners ( the concerned examiner is not my DEMT / Consultant ) about an unintended bias and how we have to work “ much harder compared to others so that they cant fail you when you are really good” . There is more to it than I can share on a public forum & I certainly wont compromise the identity of the individuals who were well intentioned.

Thanks to the appeal, the college has an opportunity to reconsider the whole new examination system. Apart from the racial divide, there are a lot of other aspects that are worthy of consideration . Whilst 2015.1 candidates got the advantage of being passed if they were borderline, the rest of the ones had to be better than that by at least 1 standard deviation . The reason cited by the college is that they need to be sure that candidates can perform under pressure. I have taken the exams twice & I can assure you that the exam pressure is infinitely more than what we face managing the most complex patients. The last examination particularly , I started having palpitations & felt very sick & could barely talk on my first day. Whilst it is easy to say we have to be better by a standard deviation , the college just fails candidates who are just competent ( borderline ) . No one has ever thought about the prospects of the candidate who has gone through the whole rigours & failed at the very end and now not competent to do anything and might have to start an alternate vocation from scratch. This is the case whilst a lot of rural EDs are manned by people who are not trained in ED. Whilst there is no point in having an exams if everyone passes , there is no point in attending the exams if the chances of passing is remote and about 10%. The college is keen to boot us out with the 3 attempt clause but most of us don’t have a plan B including myself. Whilst I am not suicidal , a lot of the time , the most honourable exit from the impasse as I see is to fall down dead. People talk about investing 7 yrs/10yrs of their life, but I have invested my everything in it and it has turned out to be a big gamble that I don’t see myself winning. Every exams that I have taken to date, I have been sure of passing if I were to put in my efforts . Admittedly I have failed before but have come out thinking I will pass next time for sure. This is one exam which I don’t think any amount of studying & preparation will make any difference. That is very disheartening. Perhaps disheartening is a gross understatement . It is very dismaying to see yourself as an emergency physician in the making for years together & to realise I don’t quite cut it.

Whilst I approve of the appeal , I believe playing it out in the public , in the lay press has been counterproductive . Not only has it diminished the standing of the college which we are all part of ( I am not sure for how longer I will be ) but has created a public perception that we are an incompetent lot. People who do not understand the nuances of the process have been particularly critical . Some speaking their mind out about how coloured people are inferior ( Facebook comments on theaustralian article) .Most people have been very judgemental ignoring a due process & refusing to acknowledge the fact that there is a remote possibility that the trainees might have a genuine grouse or even giving them the benefit of doubt .Perhaps it might not bother the thick skinned ones who decided to go public but I could not help take them personally & it has been very depressing and demoralising for me. I am glad responses have been more measured & guarded on this forum ( or perhaps has been moderated by the moderator). I am more concerned that the college would be defensive in its approach & possibly even vilify and witch hunt the coloured trainees for their chutzpah which would not only be a travesty of justice but everything the college embodies.

Disclaimer :- If I am not clear enough, I wish to reiterate that I do not subscribe to the deliberate racial bias but do believe that the process leaves much to be desired. English is my 3rd language & please forgive me for any grammatical or spelling mistakes.

So now exams are a game and not real life, failing and the cost of failure – family time, money, mental health was real to me, I don’t get 5 yrs back and am still on medication.
I cannot believe that a discrepancy of pass rates 10% vs 88% does not raise suspicion of some description.
For those not of colour you have to walk the walk before you talk the talk. I like the way the subtleties of language are being used to say that the reason you are failing is because you are not as good as us. Has any one set up a course that specifically targets what are perceived to be weaknesses of non white doctors. I don’t think so, we go to the same courses read the same books, work in the same environment but get marked so terribly differently.
There is some thing seriously wrong with the exam system, they spent so much money to “improve it” but have made it a game that is inherently rigged to favour the white doctor.

Dr Amazing,
I feel yr pain.I went through the same or more.Finally one day I said enough is enough.I silently enrolled 2 other professional colleges.Which rewarded me well and treated me well.The The door opened for wider scope.It was much better rewarding than emergency physician life ,finicially, emotionally, quality family time.,respect from patients,and job statisfaction.Bottom line yu work yr patients sincerely.God will reward yu well.Life will balance out wel every one at the endl.Don’t worry about other’s take control of yr life mate.
My only regret now , why I did not do this before.
Also yu know yr true friends stick with yu during thin and thick.

I’m amazed at how quickly some people here and on social media are willing to dismiss a racial component to the exam results. Everyone seems to agree that the exam process is less than ideal, but without acknowledging that race might be a factor, any attempt to fix it will be hobbled from the outset. Like we teach our juniors – if you don’t think about it, you can’t diagnose it.
You don’t even need to use the word racism – ‘implicit bias’ is a far less loaded and confronting term. As long as the issue is considered.

“when I asked my colleague why he didn’t report the encounter, which had dozens of witnesses, he replied that the thought didn’t occur to him as no one would take it seriously. This is a familiar theme among doctors who tolerate bullying and harassment for similar reasons.”
We can see the same in this forum as well. People including the ones who have been failing due to the racial discrimination are commenting as ” I don’t think it’s systemic racism” or “I do not not subscribe to the idea of racial bias”.
Same thing happened when the voices were raised for discrimination against women in emergency medicine. People were not ready to believe there was any gender discrimination until it was shoved into their faces by their female colleagues.

What are you talking Shata? All complaints on racism is a waste of time as they would not be heard. They will certainly deny and even if there is an enquiry it would be insane if they agree that there was racism. It would be foolish to accept. How do you expect that? Look at what happened so far, the facebook page of theaustralian , on this news, is one proof enough that Australians will not accept that the racism is going on. Best form of defence is offence. And look at this site itself. Doctors , who are Noble in their profession,( BS) they can talk about Nauru atrocities and Boat people , but when it comes to their own self, colleagues, they turn a blind eye. KN, Osceactor and Andrew all were saying there are no racism. One should keep eyes and ears open to understand this. in the era of colonialism, people were thinking that they were sincere and ethical, but they turned their blind eye to the Indigenous killings, and apartheid . They infect enjoyed it. Same is happening now. Times have changed, people have changed, but the DNA has not.

If a satisfactory response is not forthcoming then this matter should be taken to court, it will mean an end to the ED careers of those instigating this but will be for the greater good of the non white trainees who are to come. It’s a pity there isn’t an ombudsman for these sorts of issues.
It still beggars belief how people can’t see the blatant bias (racism).

I don’t think it was ACEM’s (or any other specialty college) intentions to be deliberately racist or discriminatory in their assessment process. (But then again, racism often comes disguised nowadays.) Having said that, assuming the statistics presented in the article are correct, it does raise some disconcerting questions that need to be further investigated.

As the previous comments above have alluded to, it is inevitable that cognitive bias in the form of prejudices (be it racial or gender or whatever) is present in any form of assessment process. We’re all human and it’s well studied and known that we all have preconceived ideas and views, whether conscious or subconscious, or whether we intend them to be harmful or not. This is why assessment processes to job recruitment processes need to minimise this bias through adopting a method that removes as much of this subjective prejudice; this can perhaps be looked into further.

This is not a new issue. This is the same issue that general society faces with regards to racial profiling at airports, a disproportionate all “white” male workforce, longer jail sentences for “non-white” persons, et cetera. Whilst it may be the case that for that year, it was coincidence that it was primarily “white” candidates who were competent enough to pass their exams, it is highly unlikely that such high numbers of “non-white” candidates were equally incompetent to pass their exams. Just like I would be seriously questioning the recruitment process of an organisation, if all the persons they hired were “white” males, and that they couldn’t find at least a few “non-white” “non-males” to be suitable for the job as well; that is, there is inherently bias, whether we intend it or not.

Just like the issue of bullying went ignored for a period of decades in the medical fraternity, but has now come to light and reviewed carefully amongst specialty colleges, I think the same should be done with this question of potentially biased assessment processes.

The question is what is going to happen now. I believe ACEM should launch an investigation into these claims, and if anything, review its assessment processes to ensure minimal biases; everything should be transparent nowadays. My experience with ACEM and working with its fellows have been good so far, I hope this does not tarnish it.

I just want to point out that there are some misconceptions here with the exam process .
I personally last year had only one examiner at one station, not two and not only that,
It was one who had previously been known to hold a grudge against me .
When I asked for video evidence to investigate this , I was advised that the cameras are not used . ???

Therefore this exam has a lot of bias as well as discrimination.
There is no control on personal perceptions as well as on personal bias .
The marking is so weak ! To tick as below the level or above the level leaves so much bias .
Why can’t the collage have standardised exams with proper marking sheets and valid answers with longer stations to properly assess candidates as the only excuse I get for failing is not enough time to assess the candidate
Looking forward to the review , by the way English is my first language .

One osce station only had one examiner? Probably an issue with ACEM having problems finding FACEMs who’ll volunteer their time to examine.. But sorry to hear the one examiner in that station was one you don’t get on with. I encountered something quite similar. It was a little off-putting.

How about the other 15 stations? One examiner or two? If there were two, they would’ve been marking independently from each other. The cameras watch the examiners in real time. They can even see the marking sheets.

Have you looked at the curriculum domains you failed in? Is there a recurring theme leading to your failure? The majority of stations contain medical expertise as one domain. I believe a mistake the college made was passing 88% of candidates at the inaugural written exam, who perhaps lacked medical knowledge. This has now created a situation of backlogged candidates unable to pass the osce and are failing on medical expertise.
Perhaps instead of introducing the new maximum 3 attempt rule in 2018, the college should introduce a system whereby those failing the osce 3 times can re-sit the written again to ensure they have the medical knowledge.

While I will not moderate any comments on this thread I think some of the recent commentary may be construed as offensive by the hard working, well meaning and diverse group of examiners we have in the college. Some of these people (of various ages, genders, sexualities, colour of skin tone and the rest) I know as trustworthy and honourable FACEMs.

We all have our opinions on this emotive matter. I would encourage you to express yourself fully if this is therapeutic and considered necessary but I worry about the harm that can come about when we entrench our position or point of view in a matter I consider to be complex and uncertain.

Point taken Andrew. We all respect those trustworthy and hardworking FACEMs.
We are fighting against those sort of FACEMs who would belittle the hard work and efforts of a large number of doctors saying they are not even fit to be registered as doctors. Haven’t seen a lot of the hardworking and trustworthy FACEMs raising their voice against such person. Everyone knows it happens and also who does it but turn a blind eye saying it’s “tough love”.
So the cat is out of the bag now as we have seen a senior emergency physician rant on a national newspaper about the Indian doctors and their current and previous training.
The ACEM has responded saying it will set up an expert committee and we can easily guess who would be on such committees.
I for one humbly request the FACEMs who are genuinely upset should come forward and ask for an independent investigation into this matter

Most white people wouldn’t recognize racism if it was punching them in the face. Thus, as a fat middle aged white male I should probably keep my mouth shut. On the other hand I like throwing petrol on fires so here goes.

Firstly, Andrew has been a good friend to fellowship candidates. He has allowed malcontents such as Chris Cheeseman and Ed Rege to rant about the new exam on his blog. Andrew does not believe this was a bad career move but it may yet prove to be. He has now raised the issue of racism in the exam on his blog and thus given the issue world wide exposure. The college must love that. He has also spent a great of time running OSCE’s, Sims and communication workshop shops aimed primarily at candidates who keep failing the exam. So anyone who wants to criticize Andrew can go fuck themselves.

I know that many people believe that accusations of racism in the OSCE is a tin-foil hat conspiracy theory. However, consider the following scenario. You are approached on the floor by a white doctor who wishes to discuss a case. He speaks perfect English, knows all the buzz words / phrases, has good body language, maintains eye contact and reeks of confidence. You are then approached by a non-white doctor. His English is marred by a heavy accent, he mumbles, he avoids eye contact and he seems nervous. They both present the same information but in very different ways. Which doctor do you trust? Which patient do you go and review in person? Call it racism, call it cultural bias if that make you happier but just ask yourself, isn’t possible that this is happening in the OSCE? Whitey communicates like me so I trust him and give him high marks. Blacky (can I say that?) talks funny and makes a bad impression which leads me to miss the fact that what he says is really no different to what Whitey said. As a result I give Blacky a lower mark. I think we have to admit that this kind of unconscious bias may exist.

And now the bit no-one is going to like.

I have run a lot of OSCE’s and been involved in the course at Westmead. I have failed a lot of people of all shapes, colour, age, sex (and I mean a lot! Failed a lot not a lot of sex – did I mention I’m fat?). By far the most common reason for failing people is lack of knowledge not poor communication. People try to cardiovert sinus tachy, they shove a chest drain in a pulmonary contusion, they thrombolyse a patient with cardiac tamonade and the list goes on and on and on. I honestly have no idea how some candidates passed the written. I know the OSCE tests application of knowledge in a different way to the written but still, college dudes, you need to have a long hard look at the written paper. Even more disturbing is that candidates who have clearly failed an OSCE can think they have done well and may even argue when you tried to tell then they failed. I get that people would rather believe that communication is the problem rather than lack of knowledge but if you want to pass the OSCE you need to listen to what multiple people are saying – if you are repeatedly failing the OSCE then you need to be open to the suggestion that your clinical knowledge is not good enough.

For what it is worth, my advice to the candidates is:
1) don’t leave OSCE practice till after the written
2) don’t think that just because you passed the written that you can stop studying; you need to keep revising your notes
3) video as many of your OSCE sessions as you can – you may not like what you see
4) don’t take it as an insult when someone says your clinical knowledge is not good enough – they are trying to help you
5) try and identify OSCE topics that you suck at and practice them
eg taking a sexual history

To the college, let me say
1) I still believe in the new exam but you guys are making it really hard for me
2) give the candidates who failed the written a copy of their paper to go through (it’ll never happen)
3) video the actual exam and give the candidates a copy on a flash drive (it’ll never happen)
4) have a clearly described appeals proves for candidates who watched their video (which we know your never going to give them) and think that they have been screwed
5) give the candidates feedback that they can use to improve their performance.
eg maybe have a second examiner who can write down specific things that the candidate did well or did poorly

Finally, you catch more flies with honey than you do with shit. I know you guys are angry and frustrated but some of the comments are not helping your cause.

Dear KN
Sorry if u felt that people who passed r not meritorious. i dont think it was intentional.
Same as people who failed are not all fools and did not deserve to pass.
This issue is complex and needs to be investigated transparently.
You only have to read todays article in the Australian to understand why people are so vitriolic.
An eye to an eye left everyone blind i was taught as a kid and despite being
Indian and 40 yrs old i still believe in it.

Embarrassing statement by Professor. Openly accepted favouritism by calling non-white; ‘under skilled, rote learning, lack of knowledge, criticising their medical training and even went ahead and talked about their ages’

This is after 6 years of emergency training which produce 88% of white and 7% of non-white emergency physicians.
Even the allegation of discrimination to the college are less shameful than his statement.

But at least he has accepted partiality and come out with hatred indicators that are being used.

Action speak louder than words; who faces more challenges as a registrar/ in exam/ metro jobs (FACEM).

I don’t see any drastic change, if in 21st Century we are facing prejudice in modern democracy, I don’t expect to see any change but updated smart tactics.

Dr Dunn’s full letter (from the DEMT forum intended to help all candidates) has been quoted out of context in this article. I refer to dlpthomas comment above. I have seen a similar pattern of reasons to ‘fail’ as an non examiner who is trying to optimise training in OSCE skills for registrars and students.

Yesterday we ran an OSCE course for a small cohort. the faculty were FACEMs and a mixture of ages, genders and skin colours. There was no suggestion that ethnicity was an issue to be considered . Those who are neutral or worried about the OSCE bias and not yet Sat the exam I encourage you to remain I’m a positive frame of mind when approaching your study and rehearsals.

For the doomsayers, if you need something to blame don’t single out Dr Dunn. He has a reputation for helping all candidates that ask him.

Dear Andrew
I can vouch for ur comments about dr dunn.
I have worked with him and each time i asked him to do an osce session with me,he gracefully obliged despite being brutally busy.
I remember few years ago he was the only senior doctor who went to Court to vouch for a non caucasian ED consultant in an unlawful termination case.
He maintains very high standards
and expects same from others.

I’d like to make a few comments at a practical level concerning the original article. For the record I’m a young(ish) Caucasian FACEM. I don’t have any personal experience of discrimination and wouldn’t pretend to understand the experiences of those that do. I can easily invisage how unfair and unfounded judgements may occur concerning candidates of different language and cultural backgrounds. However, I also think that communication is one of our core skills and that an excellent emergency physician will always need to be an excellent communicator (I do agree though that there are many aspects to communication, and that spelling and grammar are not the only components of this).
Concerning the “statistics” mentioned in the article however, we don’t have any accurate numbers. Would any of you accept stats in a journal article that were collected in such a biased convenience sample? (I’m not criticising the candidates that collected these numbers, they had little other options, but calling around your friends is hardly likely to give accurate results). People are calling on the college to release “the real stats” but I don’t think they keep statistics on whether people identify as Caucasian or non-Caucasian. The college does have information on where trainees undertook their undergraduate degrees ( and maybe secondary education) and it may be interesting to see how this correlates with exam pass rates (from primary exams through to the MCQs, SAQs and OSCEs). It would be interesting to see how candidates from NESBackgrounds (say non- Aus/NZ/UK etc) perform in the MCQs vs written (SAQs) vs oral (OSCE) exams. If there is little difference in the performance between the MCQs and OSCE’s it would suggest against bias. If, as many people believe, there is a big difference between the MCQ scores and OSCE scores then the college will need to look at whether this reflects legitimate concerns with communication, or unfair bias in the system.

Declaration: I am an Oriental Australian-Born Locally-Graduated native-speaking FACEM who somehow still stumbles over the English Language yet has had first-hand experience of racism his entire life.

I suspect that the issues are complex. I cannot comment on the particular circumstances of the individuals involved in this dispute. But where there is systematic bias, I believe it is more related to culture than specifically to race.

Although strong knowledge is a pre-requisite for the ACEM Fellowship exam, the manner in which one presents that knowledge can be likened to a game. It is common knowledge amongst most trainees that receiving specific coaching in this regard is beneficial.

I observe that doctors with English as a second language are more likely to struggle in mastering the elements of this ‘game’ for a variety of reasons. There are verbal and non-verbal components that sometimes can be difficult to explain or convey. Richness of vocabulary is probably not a pre-requisite (the majority of Caucasian doctors I know are not known for their poetic eloquence). On the other hand, just appreciating the subtleties of when to apply stock medical phrases can easily endear the candidate to the examiner (or trainee to the supervisor).

‘Awkward’ use of language or unusual mannerisms exhibited by a non-local are more likely to be mistakenly construed as a sign of obstinacy, uncertainty or vacillation. These can adversely affect their evaluations. In contrast, observations of this in a native-born are more likely to be considered remediable or dismissed as simple quirks of personality.

Professor Bob Dunns comments to his colleagues at the DEMT forum as mentioned above that “graduates from overseas medical schools were more likely to rely on rote learning, more likely to make potentially life threatening wrong decisions and needed tough love from teachers”
These and other comments he may have made to his colleagues would surely influence the perception of examiners and the results of Exams negatively for overseas trained Doctors .
Dunn is referring to graduates of overseas medical schools who have now passed AMC exams, passed the ACEM primary exams, passed the ACEM fellowship written exam and worked in Emergency Medicine in Australia for in my case 9 years,

Dunns comments as a senior ACEM examiner are discriminatory/divisive/show a lack of cultural awareness.

“Racial discrimination occurs when a person is treated less favourably, or not given the same opportunities, as others in a similar situation, because of their race, the country where they were born, their ethnic origin or their skin colour.”

“The Racial Discrimination Act 1975 (RDA) makes it unlawful to discriminate against a person because of his or her race, colour, descent, national origin or ethnic origin, or immigrant status.”
The above quotes are from the Australian Human Rights Commission website.

Dr Bob Dunn should be scrutinised by a discriminatory court
In the mean time he should hang his head in shame and resign as a senior examiner

@drhj: what Bob Dunn actually said in the DEMT forum, and what was written in the Australian article, are two very different things. The journalist has twisted his words and turned it into click-bait, to elicit this very reaction. The worst part about it, is that it reads as though a senior doctor is confirming what every xenophobic bigot says about non-caucasian doctors – it is demeaning to the specialty, and I worry that it will actually make life more difficult for IMGs.
Bob Dunn has volunteered many hours over the course of his career to help trainees (of various backgrounds and racial heritage) get through the exams. The fact that he has been used for this would be laughable, if it wasn’t so upsetting.

It’s best to have a discussion on facts and what is present in black & white .
Talk is cheap if it is based on insults , colloquialism and insinuations .
Please get your facts right or provide me with alternative facts .

The post was made on 14th January on the ACEM DEMT forum – 2 weeks before the allegations of racial discrimination were made.

So it is not a ‘response’ to these allegations as The Australian suggests.

It was a commentary about why trainees, in general, may not be successful in the Fellowship exam and makes no reference whatsoever to the allegations of racial discrimination- as I was completely unaware of them at the time of the blog posting.

Most importantly – nowhere in the post does it state or imply that graduates from overseas medical schools were more likely to make potentially life threatening wrong decisions or need ‘tough love’ from teachers than other trainees. My comments referred to the risk of wrong decisions in trainees whose confidence exceeds their competence – irrespective of the background of the trainee.

The quotation attributed to me as it appears in The Australian suggesting my comments referred specifically to IMGs, is incorrect.

The response in one of the emergencypedia blog posts stating that I referred to IMGs as underskilled or made reference to their age in my blog post is also incorrect.

No reference to either of these was made in my post, nor have I ever made such statements.

I am as concerned as anyone about trainees, from any background, who are finding it difficult to be successful in the Fellowship exam.

The purpose of the post was to try to assist these trainees, not to criticise them.

I agree Dr Dunn’s comments were taken out of context and words twisted around to sensationalise the story and extract this kind of interaction.
Not only Dr Dunn but almost all the senior examiners I have come across are very upright and supportive during the exam process.
These type of interactions take away the respect and courtesy we have for each other at work place.
Some people have embarked upon this type of comments on both sides of the fence and I for even a second do not want to associate myself with these comments.
We must maintain respect and dignity when writing these comments, respect for our peers, teachers and guides and dignity in our actions and interactions with colleagues.
In most cases some of the people are not even aware of the actual essence of the original complaint.
Its a process issue and college is looking into it seriously and in due course all would be updated about the outcome.The effort is a sincere effort on the part of college and is being taken seriously and I would not be able to go into the details of the process.Prof Lawler has already updated all fellows and college trainees about that.
I too, am happy to update trainees about the outcome of the inquiry either through a letter to all ( for which I have approval from Prof Lawler) or through Andrew’s courtesy if he may allow me to do so.
As a memeber of ACEM board , representing trainees, I would like to extend my sincerest apologies to Dr Dunn for these comments.

This Whole struggle is
Not to target individuals most of who are well meaning.
But
For College
1. To make the actual statistics public.
2.To make the exam more transparent
3.To investigate if there is an unconscious bias against overseas trained doctors.
4.To give meaningful feedback.

It’s best to have a discussion on facts and what is present in black & white .
Talk is cheap if it is based on insults , colloquialism and insinuations .
Please get your facts right or provide me with alternative facts .

What Statistics Do u have to prove
105 examiners of various ethnicities are all racist.
I believe there is an unconscious bias for the reasons dr thomas eloquently presented in his Blacky and Whity Post.

As a 35- 40ish Indian male working in the ED, this week I have faced a triple whammy. It was my college which I have entrusted all my academic credentials with that decided to go on record to generalise about my specifics & and call out how useless & unregistrable people like me are. The more challenging issue has been facing patients & wondering if they have read the article & know about us lot . However the most concerning bit , my coloured colleagues who have defied reason to go out on a self destructive spree taking the rest of us down with them.
I have been spending sleepless nights of late & this is no exaggeration. Perhaps for strictly racial reasons and my own situation, I have identified myself with my coloured cohort. Clearly , we are a diverse lot more vivid then the shades we come in and are equally diverse in our approach. Whilst a lot of people in the group strongly feel that they have been repeatedly failed when they have done well enough to pass & can smell malice , it was but natural for them to appeal to the college to consider all elements that could have lead to this.I am totally with my cohort on this. However what they have done since , defies reason and makes me wonder what the objective was in the first place. You would only imagine that they would want to see themselves pass in future. Going to the press at the same time as filing the appeal would not help the process. I don’t see the point in washing your dirty linen in public . As you would have expected, College has been prompt in vilifying . The whole affair has snowballed into a nightmare for the likes of me who have no control over the process and are left to face the consequences.
Whilst I can see this is a highly emotive situation for people who think they have been failed ( unlike me who was not good enough to pass on the occasion ) , generalisation about examiners I believe are as malicious as racism ( or presumed racism) . I know a few examiners and some of them have gone out of their way in helping me prepare for this exam with an ulterior motive of getting rid of me from their registrar roster. It hurts me when my friends generalise the whole lot of examiners as racist . Ever since the article came out on the Australian, I have seen some make adverse comments about at least one ED doyen I personally have great regards for. Whilst it is easy to jump into conclusions , doing so is very similar to others rubbishing the groups claim about being discriminated without even going through the process of checking . More than anything, it is best to remember there are some real people at the receiving end & it is neither ethical nor wise to make such malicious comments. I fail to understand how flaring up sentiments & generating angst among peers will help the cause.

People at the other end of the spectrum have been equally harsh for no apparent reason. As was pointed out, some tin foil hat theory subscribers have been very critical of the discrimination claims and have spared no efforts to thrash the contenders and humiliate the claimants . I sincerely wish to know what would have happened if 90% of the women were to fail the same exams consistently over 3 or 4 sittings. Would that not have sparked an internal review even before anyone could have complained ? Would the general public go on the social media & bash these people as losers & not worthy of being doctors ? Would the college have issued a statement through an undisclosed source saying most of them are not worthy of registration ? Would people have mocked at their language skills when they shared their grievance ? . People who discard any possibility of bias in this exams are as naive as people who accuse the college of organised racism . There are bound to be biases in these sort of very subjective exams and it it is just the nature of the beast. There however is a difference between bias and racism . When does adverse racial bias become racism is contentious . For me , unless there is conscious ( not subconscious ) malicious intent , it is only a bias. A lot of my friends would not agree with me on this. An unintended bias gives no consolation if innocent lives are destroyed. I believe it is not such a bad thing appealing to the college to consider these elements when people have strong reasons to believe this to be the case. At the same time, I have strong reasons to believe that the cohort will come much worse off at the end of it. To all my colleagues who think they don’t stand any chance in this system & believe can go only in one direction after hitting rock bottom, I wish to remind that you could continue in a horizontal trajectory which can be much worse. Sitting with the college & impressing them to come out with a more transparent system which can be made more objective ( like making the medical expertise more objective in a point based marking scheme & heavily weighing medical expertise over all other domains which cannot be objectified ) , making the exams recordable & reproducible as has been suggested by DLPT will be a win win situation for everyone concerned and a way out of the imbroglio. That again depends on the college`s intent & interest in the process. No matter that happens or not , we need to learn to be a bit more sensitive to everyone around us and bear in mind that the community expects us to be sensitive for the privilege that it has extended to us.

Although the claimants have come out saying racism this time, they did actually try and reason with the college for last two years to make the process transparent.All they got in return from the college was more bullshit and some scraps thrown at them as information.

The examination committee behaved as though they could do whatever they want without any accountability and changed rules as and when they wanted ,sometimes even less than 2 to 3 weeks before the exam date.The goal posts to pass the exam changed as and when the committee wanted.

After trying to deal with the examination committee in a reasonable way and failing i am not surprised the trainees took the approach of shocking the ACEM community to wake up and listen to their woes/ complaints.
Although this is a new pattern of exam and even the examination committee is trying to perfect it,the process should have been more transparent rather than keeping trainees and the DEMTs in dark and not providing proper feedback.

The trainees wont sit there and beg forever for a good feedback.something had to break and now we are all stuck in this mess.The college let the exam committee run amock and is now facing backlash.

Even now the college or the examiners rather than being objective are blaming the trainees as fully responsible for the failure.some of the examiners are not even talking to the IMGs in their hospital.The idea that the trainers are equally responsible for the failure of their trainees does not even cross their minds.If after training for 8 years the pass percentage of the trainees is less than 30 to 40 percnt is it just the fault of the trainee?
And to add salt to the wound the committee changed the number of attempts to only three without any rhyme or reason.I have known a few good FACEMs who had to have more than 3 attempts to pass the exam.now why suddenly this change? Is this a way of getting rid of people that the college does not want?

The college does not have the details about the trainee’s color or race.It cannot be seen in the written exams where they all pass.The only place the trainee’s race or color is seen is in the OSCEs when they come face to face with the examiners.It is only in this exam the results are skewed so badly that less than 10percent of the non whites pass.Now however you look into this or whatever explanation you might give it still looks like discrimination and we can call it with whatever name we want or are comfortable with.

Addendum to my last write up :- I have just read the clarification from Dr Dunn & others who have substantiated his impartiality. I think an apology is due from anyone misconstruing his letter to the DEMT forum which I believe was well intentioned.

This is my last post as I don’t believe in wasting time
Dr Bob Dunn has had a chance on this forum to prove that he is innocent of his racist comments as posted on ” The Australian ” newspaper by providing an alternate document that he may have presented to the DEMT forum.
It is troubling to see his comments as he is a “respected member” of ACEM.

It goes without saying that this forum is unable to hold people accountable for their actions
The newspaper journalist has either twisted the facts and should apologise publicly or Dr Dunn should be held liable for his discriminatory comments

I hope ACEM has a solution to this matter .
Either way the current media coverage has cast doubt on the abilities of IMGs , who like myself are now Australian Citizens . This is not just about Exams as it also affects community perceptions

If this matter is not resolved swiftly then I for one think that I will seek legal resolve through the anti discrimination Comission or similar body to clear up this matter once and for all.

After consideration of the above comments we have decided this forum will remain open (unlike other similar forums) which have now closed to further comments. To this point there has been no vetting, deleting or moderation of this comments section.

However, from now we will actively moderate the thread in good faith. Various interested parties have contacted us stating this is an important platform so this thread will remain here as an open forum. Discussion on this thread should focus on the issues around the exam including allegations of discrimination (which are allegations only). We also welcome content and advice about how to improve performance in a ‘reformed’ OSCE exam

While this is an open forum and all opinions are welcomed, we reserve the right to judge and reject comments that are counterproductive, circular in argument, directly aimed at criticism of individuals etc.

For example, if posting as yourself (or anonymously which is of course your right given the sensitive nature of the discussion) we please ask you to consider would I post this on ‘Twitter’ or ‘Facebook’ under my name? We would also ask you to avoid personal attacks on others on the forum.

MODERATED COMMENT DUE TO NAMING AN EXAMINER (not acceptable on this forum)

It is important to realise that the BRM (borderline regression method) is used to determine the standard of the passing candidate, which is a boundary between performance that is deemed acceptable or unacceptable.
The OSCE should be the one that gives you your actual marks and depending on the college or examining body +/- global score which I explained before. The global score is generally contributes a small percentage of the total score, if at all. For the purpose of the ACEM Emergency OSCE it appears they have decided not to allow examiners to have a contribution to the total ‘actual’ score. On the surface of it really sounds like a noble idea- contaminate the scene less. Sadly though this might be part of the problem as examiners are largely used to examiner driven exams and yet this is an examinee driven exam process. Their natural instinct has been to give you a global score and then mark you backwards.

It is a well known fact in postgraduate stats that one of the biggest pitfalls of the borderline regression method is – the candidate who gets a lot of tick items but fails to impress the examiner? makes sense ?
for example- you rum through a Venous Blood Gas and say almost everything on the tick items but you fail to impress the examiner —- MODERATED STATEMENT ——
This is the feel of the candidate – but this really should not affect your actual marks.

If you ask a number of examiners , all they know or willing to tell you is that this is a defensible formula. And the truth is it is one of the best amongst the whole host of imperfect methods. However its defensible only when it meets the criteria for which it is supposed to be used. Every stats formula has pre conditions. If they don’t exist- you can use it but the data is useless and can not be used to make any decisions.

For you to use the BRM you should fulfil certain conditions
1)you need an OSCE examination- the current examination process that lives the onus on the examiner, is not quantifiable nor reproducible nor auditable – is not an OSCE examination
2)examiners should have a pretty damn good idea of how a borderline candidate should perform using

a) a strict quantifiable , predetermined, reproducible criteria

To assess the quality of the OSCE itself, the formula uses data from this process
You can see how the process is flawed at this stage – very subjective and other things described before
They generate metrics eg R^2 coefficient/adjusted value of R^2 and inter-grade discrimination

Now the fact that our examiners mark backwards – determine you have passed/failed a station etc- and then go giving you marks means when a statistician who does not have intricate knowledge of the process will pass the examination as…. (TBC)

examination as being of high quality because amongst other things
—-the ‘actual’ marks have actually been manufactured to match their perception of your performance, an number of erroneous conclusions can be made and these include
1)that the exam is high quality
2)reliable examination
3)exceptional examiners – because global scores then tally with actual marks

The current examination process is very subjective
1)Too much leeway for examiners to give marks as they see fit
2)subjectivity breeds bias
3)marking backwards or by feel – improves college statistics but hides significant statistical flaws (Lets not forget almost all statistical predictions did not give one Donald Trump a chance to get into the white house – Antony Lawler needs to dismantle the current examinations board and put a new one- its too contaminated and has no idea of how to run an exam- these are the same people who did not think there was need for quarantine)
4)it is not an OSCE examination- I would challenge the college to tell me what steps of the exam are objective. They would struggle.

Simply put – the BRM is being used incorrectly using data obtained under very dubious circumstances
I would suggest we need to deal with these process issue more aggressively than put racism issue at the forefront . What if the college just comes back and say the independent body did not find any racism. Remember this is something that we can never prove. However we can prove that the processes are not meeting local standards let alone international standards and get the processes sorted out to make them accountable
The examination process is the one wee need to brainstorm on how to make it auditable and reproducible.

I have no doubt in my mind that they are extremly capable and competent doctors.
They deserve the success they have because they are equally hard working.
I have nothing but praise and admiration for these doctors as I have not come across a single UK doctor who is less then perfect and that after working there and after my interaction in Australia withs everal doctors from UK who have worked as my junior residents , my colleagues and my consultants.

I am not sure where those stats about UK doctors come from but can vouch for their competency . I am totally with Naveed on this . I am proud to have worked alongside a lot of these doctors . Since the issue has been raised, I would like to provide some real statistics published by the AMC in 2005 when doctors graduating from every country other than Australia /New Zealand also had to do the AMC exams. Please note that even back then, UK graduates had among the highest pass rate at about 66% overall ( inclusive of OSCE exams) , about 10% more than the Indian graduates who have mostly turned unworthy of registration since passing the exams. This is not a sample but the real deal – complete numbers from 1978 to 2005 & substantial ones . I also wish to draw your attention to the fact that these unworthy graduates had a better pass percentage than graduates of some of the other English speaking countries .
I wish to make my point that I am not trying to cast aspersions on any other nationalities or individuals but can`t get over the fact that the college felt it appropriate to spray the whole lot of Indian doctors with contemptuous malicious statement in order to get back at the claimants .I am sure this is the driving force for a lot of us who are otherwise happy to sit back and watch the drama unfold.
This is based on the information provided by AMC to the 2005-06 candidates in an introductory handbook & I can personally vouch for the veracity of its source . A google search will lead you to the copy of the booklet possibly copied from a Government website but the actual website has taken it down since.

India 56.25% passed . Total attempting the exams 1337
Srilanka 62.69% passed. Total attempting the exams 579
UK 66.48% Passed. Total attempting the exams 528
South Africa 69.1% Passed. Total attempting 424
Please note that nationalities of one of the countries whose primary medical degree is now recognised under the competent authority pathway for exemption from AMC exams had a pass percentage less than the Indian graduates as of this data.

The statistical conversation is interesting – I would be interested to hear more about this.

The use of both Entrusbable Professional Activities (EPA is the scale of marking in WBAs from no supervision to lots of supervision) and Competency Based assessment (OSCE with standard setting) is also interesting in my opinion.

On the one hand we are using EPA to say – ‘yep she can tube at 3 am on her own‘ – BUT then we are saying actually in an OSCE setting I don’t think you are ‘competent’ at intubating.

Gestalt creeps into an OSCE at this level (understandably and appropriately) – and perhaps a rating system in the EPA would benefit from some objective concrete points to say – “yep I trust you to do that at 3am” Doing the WBAs properly is a key point here. One option would be to have WBA processes observed externally, another would be to have peer hospitals assessing each others candidates on set days (e.g. a pair of FACEMs from outside do 10 registrars in a day)

1. All the courses trainees go to give them written and verbal feedback. As Dr Thomas said they tell the candidates I fsiled u because u shocked a ST. It is so obvious that the trainees are benefitting ftom these interactions. Areas neglected are highlighted and gaps in knowledge identified.

The in between time still is three minutes and
there is clear intent to provide constructive
feedback.

2. The ratio of pass/ fail is not grossly lop sided in these courses.
Feedback comments are never subjective like some I have seen over the previous month or so:

How is a trainee supposed to improve the next performance if feed back paper just says

1. More detail
2. Scattered thoughts
3. Paternalistic attitude
4. Ressus Feed back which is like a twenty minute station where u have to do a hundred things just says ” handover not succinct”

Well said Naveed.
We all know what the issue is.
The college and examiners have set up a system to filter out Who ever they don’t want with no need to explain anything to anyone. Such an arrogant attitude.
If this matter have been kept quite and ignored then the college would easily continue that process forever.

Sorry Andrew,dont agree with your comment that it is appropriate for gestalt to creep in an OSCE at This level..
Gestalt is subjective and guess work/ gut feeling. People have struggled and worked hard for years to get an opportunity to be in the exam.They have earned the approval of their senior colleagues working along with them for years to be in that exam.After all that hard work someone who doesnt even know you strolls in and uses Gestalt to determine whether you are good enough…. Dont think its appropriate or understandable.

Its called an OSCE for a reason – Objective- not subjective ,not Gestalt or Take a guess exam.

No its not understandable or appropriate…
If we agree that Gestalt is appropriate in this OSCE then it also means there is an unconcious bias which is what we have to avoid.

‘Gestalt’ or feel of the candidate is already accounted for in a proper OSCE Andrew. This is what may be referred to as the global score. The interpreation or how this gestalt or global score is used depends on how the particular examining body wants to set the ‘standard’ for the examination. You can’t double dip if you are going to use the borderline regression method. Your gestalt is the one that is going to be used to set the standard of the examination and so technically should not contribute to your actual marks (though this is not absolute but extremely desirable)
The current examination is being run on close to 100% gestalt and marks you backwards which is wrong.
This is an improper use of the borderline regression method.
It is from this significantly subjective form of examination that I feel some of the bias, probably unintentional might or might not be coming from.
From that point alone the process should not have used the borderline regression method
The examination process itself can not be called an OSCE
The potential for bias is plenty – what that bias is I honestly do not know, but it seems if failing the exam can be easily predicted by certain personal characteristics. That is scary Andrew.
We all should be very afraid

I hope I find all of you guys well. Now that the ball is fully in motion, there is no turning back. I hope I will be able to dwell on some process issues that I feel we are neglecting and probably might explain such a high failure rate amongst non-Caucasians. To deny that racism is playing a part would be folly, but to also emphasise it as a fighting point is missing the point.

I hope you guys appreciate that, who passes is determined by borderline regression method which sets the standard of the examination and that is dependent on the results input into the formula from the ‘OSCE’ examination process.

Now it’s important to understand and realise that the robustness of any formula is dependant on the quality of information that has been input into it. The quality of the data as in this case is dependent on how robust the ‘OSCE ‘ process is because that’s where the data that determines who passes or fails is derived from. Forget about the borderline regression method for now. The question should be -does the ‘OSCE’ examination process meet the minimum standards accepted for it to be called an ‘OSCE’.

The hallmark of an ‘OSCE’ examination is as the name implies- is objectivity. It is my assertion that it is at this stage that ACEM fails considerably.

The current examination process as defined to the examiners by ACEM examinations committee (for which I believe Bob Dunn is a member) is

An ideal OSCE is
1) objective
2) reproducible
3) able to have easy recall
4) audited

To ensure objectivity
1)all candidates are examined on the same stations over the same duration of time
2)as you progress through the station marks are awarded against steps that you have gone through. This is usually on a trinary method, but could be any method including eg binary
3)confederates are given detailed scripts to ensure that the information they give, including emotions etc is the same to all candidates

An objective marking scheme ensures that who passes is not dependent on the examiner but on how much of the tick items you have gone through. The marking scheme should be clear and reproducible to an extent that if someone were to get a video of how you performed they would still be able to give you the same marks as the examiner before or the next examiner. They might differ on the global score- but in true OSCE terms that does not matter for you as candidate .In essence what this means, and its important to understand this very subtle difference is -2 candidates can both be marked as being borderline by the same examiner (this is the global score- the eel or impression of you as a candidate)- but one might have 24/30 and the other 12/30. This is because whilst the examiner thought you were both clumsy- the other one went through more tick boxes than the other. This is objectivity. Your feeling as an examiner don’t matter. The examiner gets their chance at scoring you on the global score.An example is the 110 OSCE green book-the marking there is unambiguous and reproducible egDid the candidate wash their hands? no (0) , partially achieved (1), completely achieved (2)- this is called the trinary system
This is objective- you get marks for what you did and said – fair. This also means should you query your result – its easy to audit how you got the marks. makes sense? I hope it does And you also see how easy it is for another examiner to score you almost the same as the other examiner. The global score is sometimes quantified and sometimes not- I refer you the green book again. Notice however – no matter how its scored – the global score permissible for the examiner is always a small percentage of the total marks. This is because worldwide it is recognised that if you bring in a lot of subjectivity – you risk introducing ‘more bias’ and lose the meaning of the results. This is however different from defensibility which the college always try to scare you from putting in an appeal for your results.
Now the exam we have been exposed to meets none of the criteria- it is a subjective examination that allows the examiner to use their discretion without them being auditable and the process next to being impossible to repeat, hence the mess we are in now. This is not OSCE examination. It is not an objective examination. This is what we should be fighting for.

Now I urge you to go to the ACEM website and look at the marking sheet from 2016 July examination
You will notice that
1 a)the tick items have no quantifiable marks attached to them or next to them
b)there are bolded items that no one knows what they mean, why they are bolded, how much they contribute to the domain and if they are pass/fail items
Ask an examiner near you- they are likely to have no CLUE
Don’t waste our time asking your DEMT-he will send you on a wild goose chase and is unlikely to know the new examination process

This means that each domain, in real mathematical terms is no
t1)quantifiable
2)not repeatable
3)not auditable – because who the hell knows what the examiner was thinking when they were marking you, and the basis for it
This is in statistical terms is – non objectivity- or increased subjectivity.That is where the majority of the PROBLEM lies for us
Subjectivity breeds bias
An non auditable examination means no individual is accountable
Human beings are prone to bias – this is an undeniable fact. They need boundaries. Sadly ACEM has not provided these for the examiners

Now how the exam is marked is marked has turned out to be the following
-You get into the exam station
-The examiner – writes down on their chart whatever they are writing down
-They first determine that you are borderline candidate
-Then they go back to your mark sheet, and put marks that are congruent with someone who is expected to have a borderline pass- and the reason for this is exactly as above. It would be weird to mark someone as borderline and give them 7-6-5- but this is a known phenomenon with the BRM (th candidate who goes through the tick boxes but fails to impress the examiner)
This is why you feel like you said things that might have been on the sheet but you still fail
An analogue would be like if you imagine you are practising with the green book with your friends – they discuss and say your perfomance was borderline and they circle borderline perfomance – this is the global score and then they work your their way backwards / makes sense (however because there are tick items in the green book that are quantified – this is difficult to do, but however if you are using the ACEM marking sheet you have a guideline that not quantifiable and therein lies the risk for bias) – this subtle difference is very important to understand as it has significant advantage for the college when they go through their results to verify different parameters
Its like (remember algebra)matrice A but only that the mathematician is starting with a transpose of the matrice – I know this does not make sense to plenty of you but hey.
Any person or educator of any kind will appreciate you can not call this exam an OSCE because it aint, and you can not use the results of this current examination to use the borderline regression method. I will explain this in my next e mail
Feel free to ask any questions or critique.

Any’s comments are fascinating. I do not understand how the OSCE is marked. This bothered me so much that I spoke to a statistician and I didn’t understand a word he said so I gave up. My advice to the candidates has always been to forget about how the OSCE is marked and just read the question and make sure you address the domains. However, many candidates clearly (and perhaps justifiably) do not have faith in the current marking system and statistical analysis and that is a problem.

The first time some-one asked me to “mark” their OSCE I was quite nervous but I was told not to worry because there was a marking sheet. However, when I saw the marking sheet my immediate reaction was “what the fuck is this?” I’m sure the marking sheet makes more sense to real examiners who have been trained in its use but I do not like it. You simply can not give a candidate detailed feedback of their performance from the marking sheet. (and by detailed I mean feedback that would allow a candidate to identify areas of weakness and thus enable them to improve their performance if they fail).

As I suggested elsewhere, I believe you need a second examiner writing down specific examples of things that the candidate did well or poorly. In this way problem areas could be identified and discussed with a failed candidate who then knows what to improve next time.
eg in several stations the candidate interrupted the actor
in several stations the candidate failed to follow up on things the actor said
consistently using too much jargon
wrong drug dose
made a “fatal error”
candidate looks like he throws his doosra

As things stand, we can ask for detailed, individual feedback till the cows come home but we aren’t going to get it as it simply isn’t possible with the current marking system. And until the college provides detailed, individual feedback, failed candidates are going to remain very, very angry.

I must admit all your posts have been the best in this forum.very fair and making sense to all parties involved,wish the college and examiners follow your path and show some honesty at least.
All we after is fairness and untill we make sure that happens we will not give up.
No more b…shits from ACEM

Just by telling the candidates after 6 years of doing everything right “sorry ,you don’t deserve to be regsitered and practice in Oz land”

Feedback is important, however my issues are with the examination process itself. It can not be called an OSCE examination.
Did you feel when you were marking the OSCEs that you were being objective?
And what quantifiable criteria did you use to rate the examinee ?
Did you think you would give the examinee the same score for the same perfomance in 2 hours time?
If you were to be auditated as to how you got the scores, do you think someone independent would be able to figure out why the examinee got the marks they did for that station just be looking at a pre-recorded perfomance?
Thats how a high stakes exam shoudl be structured
The fact that you would be unable to guarantee any of the above – suggests as very subjective way of examining. From a statistics point of view – this is concerning

Hi Naveed,
Agree its a system issue and might not be racism.
But the college lost the trust of the trainees when it left an incompetent examination committee to screw up the lives of its trainees and time and again turned a deaf ear to the pleas from the trainees.
The trainees had to shock the college with the ” racism defibrillator” to wake up and listen to them.
Now have to wait and see who will be in the committee that the college will set up to investigate this issue.

College does have a fair ,robust and transparent system in place – only on the paper as the trainees found to their detriment for last 2 years waiting for it to activate.
All the committees,subcommittees are made up of the same people who will make sure their a**es are not hanging in public.

Where was the talk on “respecting the candidate” when they were given atrocious feedback on why they failed. In fact the feedback was so poor that they (I) did not really know where to go or what to do with it.
It was very respectful.

Lets use gestalt – the investigating commititee will be made up of well established not well intentioned college members, there will be no external investigator.
In the guise of confidentiality a non transparent process will be Implemented.
RESPECT.
By the way has a non Caucasian ever won the Buchanan prize?

A quick google search for ACEM Buchanan prize honour role will reveal some winner’s names that do not sound caucasian e.g. 2013.2 Theresa Chow, 2010.1 Angela Lin Chew, 2005.2 Sharif Elgafi, 2003.1 Darren Lien. There are other names on the honour role which also appear non Anglo-saxon in origin, and perhaps non-caucasian. I hope this answers the question. Sorry it doesn’t fit the agenda here.

The current feedback to failing candidates does address the curriculum domains they’ve failed in but I agree that failing candidates deserve more detailed feedback than this, with particular examples of mistakes or omissions they made. In the ideal world, the exam would be recorded and played back to settle disputes if required.

The current group repeatedly failing registrars, mainly IMG’s, whom I believe call themselves the ‘trainees union’ are so convinced of discrimination from the college, I wonder if they would accept it if a review actually vindicates the college?

The only way to settle this problem is simple
Have an examination process that is transparent, auditable, repeatable and conforms to accepted standards -simple
However I feel you have missed the point
The prize winners you have mentioned were not examined under the current processes
That in itself means they can not be used as part of the current discussion because the circumstances are vastly different
makes sense ?

Phillipa , thanks for being a part of the dialogue ( or rather making it one) and we sincerely appreciate your efforts. We are aware that the IMG pass rates are reasonably high , mostly thanks to the UK & Irish graduates . Could you please put all these conspiracy and race claims to rest by confirming if the pass rates are actually high enough for the coloured trainees . No one has actually said anything about IMGs so far and the discussion has been mostly centred around skin colour 😦 . I sincerely hope the college will continue to engage in this dialogue .

FyI the college will always tell you our data are wrong as we have been told that individually many times but their data are skewed as they include UK graduates with the IMG.
Dear ACEM do the data correct and be transparent at least once ane only once .

There is another thing I forget to mention above. Many of us feel that the college needs to provide detailed feedback to those who have failed. I believe this would help but it would also be naive to believe that all candidates are going to be satisfied with, or accepting of, the feedback they are given.

If you failed the old exam, you got to go through your paper with an examiner. This could takes hours and the examiner had to this with multiple candidates. Whilst this sounds like a useful exercise, many (most?) candidates came out of the feedback session more pissed off than they were before they went in. (The anger was often directed at the pass / fail criteria which seemed unfair to many candidates. eg This is a strong answer. It’s a 6 if not a 7 except you didn’t mention that you would give the patient a Hep B vaccine so you only get a 3.)

Whilst I believe that more detailed feedback should be provided, it is also important that the candidates accept what they are told. In my experience, not all people are not willing to do this.

In my experience,if its a good feedback, even though candidates initially deny it, will accept it once they start thinking straight.
But if its BS no one will accept it. Candidates are not just starting medicine to accept whatever they are told.The good candidates will have questions that the person providing feedback has to answer,not just brushing them off saying just accept what you are told.candidates will accept whatever you have told, when they are trying to kiss your ass.
In this case the college pointed fingers towards the DEMTs for the feedback who themselves were clueless ,and who in turn pointed finger toward the trainee and said “you must be shit thats why you failed” but dont ask me why you are shit.
Whenever there is a need of complex and multiple explanations needed to justify the actions, it only means that there is something wrong going on and people are trying to hide it.

Dear Toby
Agree with your comments.
But if college was to shove our answer sheets up our … then there will be very little to complain about.
People will learn after 1st, 2nd , 3rd or 4th time what mistakes they are making and can improve from there.
It will immediately solve all the bullshit about racism and bias.
At present there is no such process and hence finger pointing at our beloved college.
Despite all sincere efforts to get better feedback from college, it has taken 2 years and media attention for the dinasours in the college to get off there ass and do something about this.

Ryan, I am not sure what happened to you, I wasn’t there – but here is my subjective unsolicited opinion on your situation as I read it on the evidence of your comment(s).

– You were told directly by your examiner/DEMT you have not passed and you are NOT ready to sit (see my comments in the blog about DEMTs predicting who will succeed in the exam)
– You interpret this directness/honestly as ‘racism‘
– You have 9 years of experience as a registrar – but this may or may not be relevant in this case – quantity does not always = quantity (e.g. my site has lots on it but it is not necessarily all good)
– You sat the exam and were not successful…
– You then blame racism (for not passing) rather than saying, OK you were right, I wasn’t ready to sit this exam
– Cycle complete

I would gently put it to you regarding Prof Dunn’s forum comments that, in my opinion, he is actually trying to help all the ACEM candidates with his shared thoughts. In general, from what I have seen, DEMTs are doing their best to help.

Andrew
You can only help people who want to be helped. Prof Dunn’s comments on how to improve your perfomance are spot on and anyone who will brush them off will do that at their own peril. Sadly improving one’s perfomance in the current context of the examination is difficult to quantify because the tick items are not quantified by ACEM as a board. It leaves that to the discretion of the examiner – and thats demoralising .

Every human being has the potential to improve-no matter what your baseline is – up to a point. Anyone ignoring his advice needs to reconsider their stance.
However we need to make the examination process objective, quantifiable, auditable, marker repeatable and conform to acceptable local and international standards and proper use of formulae

Regarding the issue of feedback. In general needs to be specific and timely, but feedback following assessment has always been a challenging issue – it’s emotionally charged and priorities for candidate/examiner may conflict

With my educator hat on, when it comes to preparing you need to ensure that the quality of your practice, rehearsal and feedback is at the highest possible level. So that means, NOT casual OSCEs over skype, NOT reading a text book, but instead repetitive practice with immediate feedback and correction of errors. Some video might help too.

On our course we do an OSCE for 30 seconds, start again, re start 1 minute, 2 minutes and so on (feedback with every segment). This is a educational model known as ‘rapid cycle deliberate practice’ (Hunt et al https://www.ncbi.nlm.nih.gov/pubmed/24607871)

lets not beat about the bush.
Can I please ask how many white and non white passed exam?

Regarding Bob; why are you victimising candidates? we did not publish his hostile views about non white in ‘The Australian’.
If he is innocent Why doesn’t college take action against the responsible media?

I find myself suspicious of brash Whitey when he seems so sure of himself. But when I trouble myself to investigate a bit further, beneath it all there is actually no substance to his statements. Whereas, Blackey’s stuttering outward performance upon questioning actually reflects a much more thorough and considered response.

I’m not quite sure which of my comments you are referring to. I have been careful not to say anything that could be misconstrued as saying that one group is better than the other just that they communicate differently which could lead to a bias in how they are marked. As to being “brash”, that is hardly restricted to white candidates. Tell me, had I said that non-white candidates are brash, would now be loudly denouncing me as a racist?

As to my comments about candidates being reluctant to accept negative feedback, that applies to all ages, both sex’s and all ethnic groups. Frankly, it’s just human nature.

I wasn’t accusing you of this. But what I am saying is that unless is aware of the impact of the ‘halo effect’ we may succumb to the bluff.

When I was preparing for the Primary Exam many moons ago, I was told that if I had a strong opening I was more likely to be forgiven for minor errors whereas I would be heavily scrutinised for every word if I had a stuttering entrance.

First impressions count and examiners get very tired after the umpteenth candidate. Now that is human nature.

I hope people’s anger (mostly justified from an organisation that has negelected their concerns ) will not deter them from seeing reason and posts that are constructive.
There is too much anger but this wont get people anywhere. I think you have been fair in your comments. And thank you for providing that on this forum.

Dear osceactor
Thanks for the information about buchanan prize winners.
Regarding recording of the osce- i think there are cameras in the rooms and there is a control room.
I think exam is recorded but like many other things related to the exam only college knows the truth.
Regarding individual domain feedback- yes we are told you got 2 in professionalism but WHY is a BIG secret.
One of the very high up in the Exam Committee said to a trainee that its just examiner”s gestalt when they mark the candidate even for individual domains.
I am not sure where you got the name for repeatedly failing IMGs group called Trainee Union, as far as i know we haven’t called ourselves anything yet.
I think trainees will accept a transparent , thorough review conducted by an impartial body.
But If the review finds that there is a bias will college retrospectively award Fellowships? or Compensate for the Losses?

Hi Any. No problem. The honour role can be seen by anyone with access to internet so I couldn’t understand why there were claims of a non-caucasian never winning the Buchanan prize.

Oludara Jones states that all the non caucasian Buchanan prize winners were from the old exam format so they don’t count. I disagree with this. Although the old exam format and marking system was different, discrimination could still stop examiners/examiner pairs from awarding the prize to non-caucasians. I agree with the need for transparency, repeatability of the new system though. I also agree with a review, if a significant number of candidates feel an injustice.

To answer your question, if the college found bias was involved, would they award compensation or fellowships? Well, it would be justified if they did. But I strongly doubt bias will be found, especially not repetitively for the same failing candidate(s), and to be frank I don’t think it is good for the standards of our profession if a large number of borderline candidates are awarded a fellowship. Also remember the current ‘borderline pass’ is actually cut score plus 1 standard deviation. A failure of say within 5% below the cut score can be further away from a pass than you think.

Yes the AMC centre has ceiling mounted cameras. They can zoom in and focus on different parts of the room, including the examiners and their mark sheets. (I do not know if performances are recorded). Senior examiners watch from the control room. Additionally, senior examiners come into the osce rooms and watch some performances. In the 3 minutes between candidates performances, the senior examiner supervises the marking from the examiner pairs. All of this information is no secret and can be easily worked out when you enter the examination area and walk past the window where there are several people watching screens and wearing headphones.

During the marking what I have seen amongst different examiner pairs is blinded individualised marking, then comparison of these between examiners, which almost always match. There is no time to conspire against candidates. The examiners mark sheets (examples can be seen from 2016.2B osce) contain closed marking objective items which the candidates score on, or not. If the examiners mark sheets do not match, the examiners go through these items to compare if they were achieved or not. It is wrong for an examiner to say it is just gestalt and understandably this type of suggestion would infuriate the complainants.

Almost every osce has medical expertise for at least one of the domains, with the others being communication, professionalism etc. Perhaps it is these non-medical expertise domains where IMGs have trouble, and I would also suggest that medical expertise can appear better with better communication, confidence etc. If you got a ‘2’ in one of the domains, I would suggest that you actually performed very poorly in that domain; discrimination played no part. But I agree that detailed feedback could help you improve.

I wish ACEM was as forthcoming with such information. We will have to wait what college comes up with after self appointed Review Committee in terms of compensation etc.

I agree we have to maintain very high standards for our profession except recently i have seen fresh FACEMs giving Adenosine to AF, No Bicarbonate to TCA overdose. You can brush these off as anecdotal incidents of which you don’t have any personal knowledge of.

How do u explain such high statistical variation in Pass Rates between different demographic groups. Why do you think all of these 80 odd people repeatedly fail despite performing at same standards on floor with their passing counterparts, performing equally well in trial exams, having same performance in practice sessions.

I DISAGREE WITH YOUR COMMENT ABOUT EXAMINERS MATCHING THEIR MARK SHEETS BECAUSE MOST OF MY OSCE STATIONS HAD SINGLE EXAMINER AND HENCE HIGH POSSIBILITY OF EXAMINER FATIGUE, UNCONSCIOUS BIAS AGAINST NON FLUENT ENGLISH SPEAKING CANDIDATES ETC ETC.

Why can’t those closed marking objective you are referring to, be transcribed on the marking sheet and ticked off by the examiner and then given back to candidates as feedback if they don’t pass. IT is very simple, Just look at the green book from UK.
How come apart from chosen few understands this complex statistical algorithm although i feel its a less of an issue.

I know of a candidate who got 1, 1,1 in neurogenic shock osce in 2016.2 exam. As u know this is the lowest score u can get. i wonder what u have to do to essentially get 0 marks,apart from the fact someone didnt like your face. When he asked college for the examiner notes, college said there were no comments written on the marking sheet. He seems to think he did well to get to a correct diagnosis and appropriately managed the hypotensive trauma patient. Again I’m sure you would refrain from commenting on individual cases.
I have personally felt that if i did well in a station i got 4,4,4 and hence still fail and if did slightly bad in a station i got 3,3,3 etc on lower scale of the spectrum.

JUST for your info The Gestalt comment about the candidates came from none other than DEPUTY CENSOR in CHIEF.
And hence the whole fight is to get this GESTALT out of the equation.

It would be impossible to comment on the cases you mentioned unless I was there myself. I can only say that a score of 1,1,1 means that even if the examiners ‘liked the candidates face,’ and gave him 3,3,3 instead, his performance was still likely a miserably failing performance. Bias was not to blame for failing.

I’ll give you some further insight into the marking from my perspective. Some stations are better discriminators than others in the exam, requiring a very strong performance to pass the easier ones. For example, say there is a station on procedural sedation to reduce a fracture. This might be considered very basic/run of the mill, and the vast majority of candidates might score in the top two columns of the mark sheet. Thus even if you get say a ‘5,’ you’d still be below the passing cluster for that station.

Which osce(s) did you do? In the first two osces, I think it was 2015.1 and 2015.2 there may have been some stations with only one examiner. But from 2016.1 onwards I doubt that any stations had only one examiner, and if there were, there wouldn’t be enough single examiner stations for bias to be a major factor in failing. The scenario I describe i.e two examiners blinded from each others marking is applicable to the vast majority, if not all of the stations since at least 2016.1.

I think it is the case that too many people got through in the 2015 fellowship exams, rather than not enough getting though. Firstly the 2015.1 written exam had a 88% pass rate. Of these, I recall around 70% passed the osce. I have heard anecdotal cases where some of these new FACEMs from 2015.1 went on to perform poorly. The assessment was too soft, not too hard.

Regarding those 80 or so candidates who keep failing, my guess is they were some of the original candidates who did the first written exam where a pass could be gained despite lack of medical expertise. It would be useful for the college to inform candidates of their written exam score if they have serially failed the osce. Likewise I think the new ‘three attempt rule’ from 2018 is a little too harsh to impose on candidates who have spent several years training. It would be fairer to have mandatory re-sit of the written after say failing the osce 3 times. After passing this re-sit, perhaps the three attempt rule should then be applied. Perhaps a mandatory skipping of the next osce may also help candidates pass their next attempt. The extra 6 months might be valuable to help reflect on their deficits and improve on them.

I agree with the feedback issues you have mentioned. They would help failing candidates understand at least part of the reason they fail, and prepare them for retaking. In reference to the Green book, my advice would be it is a book that prepares junior doctors for a junior registrar level exam (the MCEM). Although the marking templates may be useful, don’t equate ticking the boxes in the green book template to a passing fellowship osce performance.

I have also been on courses where I see IMGs arrange to ‘Skype’ each other in future for osce practise. I believe this is bad for at least two reasons, they might reinforce those factors disadvantageous to IMGs in an osce, and worse positively feedback to each other. The other reason is osce practise should simulate the real osce as closely as possible i.e. 3 minutes reading outside the room, enter the room and introduce yourself, sit next to the actor at a specific distance etc.

It isn’t really surprising if IMGs have lower pass rates, and it would be naive and perhaps a little entitling to think they should pass just by simply ticking the boxes on a template. The scenarios require domains other than medical expertise to pass them, and this requires skills such as clear verbalisation, empathy, display of confidence, following prompts etc. Some cultures may struggle with acquiring these more than others. Perhaps it is this reason, rather than phenotypic appearance contributing to their serial failures. There are also several native English speakers, some of whom are clearly caucasian in appearance who failed the osce. The ones I know also struggled in the non-medical expertise curriculum domains, due to their personalities. And in the case of many serial failers, caucasian or not, lack of insight and response to feedback from peers seems to be a major factor.

So now after all these previous osces all agreed that the college should have provided feedbacks
Why no one neither from the acem or anywhere else said that before .
This is a major issue which we all wanted but the ACEM arrogance just keep ignoring that
Their excuse last time was that the too lasy to do that as that means to have to make new osces.
For God’s sake stop putting the blame on candidates only.
At least any college or training body should have some commitment to their trainees

I can understand that your medical expertise can fluctuate between 1 and 7.

What i don’t understand is how your communication can fluctuate that much.

For example, the neurogenic shock station mentioned above with marks: 1,1,1. If this candidate was ‘very poor’ in his medical expertise he should get a 1 in medical expertise but this should not effect the score of his communication. How could he score a 1 in communication. whilst this candidate would have passed his IELTs which checks your communication skills.

I myself scored a 2,2,2 in AF/defib. teaching station. my teaching skills went down from 6 in previous station to a 2. I am pasting my score from ACEM feedback sheet but unfortunately it doesn’t get pasted in the table format.

Did the similar stations to the real exam at the TEEMWORK course and score was well above standard. lol…
While I was given the reason for scoring low, coz I didn’t sync it (though I corrected myself immediately after prompting and did go on to explain what could happen if you don’t sync it, R on T and what not.) But this MISTAKE was taken as an ERROR and I was marked down to a mere ‘2’

Having said that, and even accepting my POOR medical expertise in this topic (having done it countless time being a dual ED/ICU trainee), what I don’t understand is how my teaching skills went from a 6 in previous station to a 2 in a matter of 3 minutes (reading time).
one explanation the examiner didn’t like me. other explanation i am very bad at this though i been doing it for 8 years now. (4 years advanced training + 4 years doing exams).
The big problem is that the domains are Not individually marked. If they THINK that you are bad in expertise then you communication/ teaching or other domains will have same marks (pretty much).
Just goes on to tell you that this is NOT OSCE but SNCE. ( subjective Non-structured clinical exam).

I’d be very unhappy if I had 10/18 stations with only one examiner. On the other hand, is it possible your spending too much time looking at / worrying about the examiner and not enough time concentrating on the actor? I couldn’t tell you anything about any of my examiners as I made a point of never looking at them.

I have heard this argument about people passing in 2015.1 written exam who were not good enough.
Why did college do that?
Who is at fault if college passed the non deserving candidates?

Many of those trainees are now Consultants. Whats College going to do about it?
If this is the reason we continue to fail then college did a big disservice to those candidates by passing that written exam. Who is liable for that?

If your argument is correct that some of us were non deserving then atleast i would have spent last 2 years improving my medical knowledge instead of trying to change my accent, mannerism etc. to improve examiners GESTALT about me.

How much studying have you done since passing the written? One thing I keep telling people is you need to keep revising your notes even after passing the written exam. Everyone concentrates on communication skills but clinical knowledge is the biggest domain. I believe it is a huge, dare I say “bigly”, mistake to assume that passing the written means your clinical knowledge is good enough to allow you to stop revising your notes prior to the OSCE. (Not to mention that in this business you can never stop studying.)

Yes, I believe that a pass rate of 88% of those who sat the first ever written in 2015.1 have been done a disservice if they did not actually deserve to pass, if they are now in limbo unable to pass the osce. This is why I advocate for a chance to re-sit the written exam with another 3 osce attempts, rather than the ‘three strike and you’re out rule,’ effective from 2018.

I wouldn’t be able to answer why the first written/osce exams allowed such a high pass rate but I think it’s a little too late to single out that cohort and re-test them because amongst that group there would have been some candidates who were capable of passing any of the subsequent written or osce exams.

I also advocate candidates knowing their written exam marks if they’ve failed the osce. Like you said, it would guide preparation for future attempts. But remember that the non-medical expertise domains are still important and require ‘deliberate practise,’ particularly if candidates do not perform well in these domains, which culture may impact on. I recommend simulating the real osce as closely as possible and getting feedback from selected people, not other candidates or consultants who want to be nice.

Although it wouldn’t be difficult for future candidates finding out what has been asked in the past, I’d check if your list of 2016.2 stations breaches the confidentiality clause you signed when doing the exam. It is surprising if 10/18 stations had single examiners, but let’s say they did. Do you think there was enough bias amongst the 10 single examiners to result in your failure? Did you ONLY fail those 10 stations with single examiners? Did you pass some of those single examiner stations? How many of the two examiners stations did you pass?

To “Any”
– This exam is not marked like a typical OSCE for say students. There is no specific tick boxes for each step so as an examiner you need to judge domain performance. My understanding is each station comes with specific criteria defining each domain (which is why it is loosely called an ‘OSCE’).

– I think having one examiner is ok as long as the process is audited, video is a good idea but it will probably never happen…

To “last-OSCE-attempt”

– I don’t think the domains can be totally separated from each other actually. If you do badly on one its hard to do well on the others… Like dlpthomas said above = You shock sinus tachy, chest tube a pulmonary contusion, frusemide a pneumonia – you are going to bomb that station.

– Medical Expertise and Communication are likely to go hand in hand with each other in most cases. For instance, if you shock the sinus tachycardia in the exam – you are wrong – this is not ‘medically expert’. With this action your communication domain will also suffer as a result of the examiner seeing that you are not only full of s**t but also talking total nonsense… Video yourself, you might be shocked (that you are in fact talking total nonsense).

Likewise, in a teaching station if the ‘expertise’ is not up to scratch this will drag down your marks for scholarship, cos – well you’re wrong… Latent self correction is likely to be irrelevant (too little too late) because it will be often interpreted as uncertainty and leave doubt in the examiners mind.

So again, it comes back to both what you say AND how you say it. Training in body language, communication and OSCE strategies that we teach on our OSCE course and at http://www.emergencypedia.com/osce can get you so far – you also need to be certain in your medical expertise to be successful

Dear osceactor
The list of osce stations is available on college website for anyone to look at so i don’t think i have broken any confidentiality clause.
I am surprised you continue to defend college’s twisted ways and try to scare me off with the confidentiality clause.

Any.. I’m not trying to scare you off by mentioning the confidentiality clause. I’m surprised you took it that way. The intention was to remind you of the clause in case your comment puts you at risk if your anonymity is ever lost.

If you look back at what I’ve written, you can see it’s all insightful information. But it seems you opinion of the college is a foregone conclusion regardless of any potential review and your antagonistic response to my comment is making me begin to understand you a little more.

It’s cool – even my wife thinks I’m a bit of a dick. Interestingly, she has commented many (!) times on my inability to accept feedback. (eg “How many fucking times do I have to tell you. you hippy shit?”)

shame, victimising and terrorising poor candidates, They already broken by your barbarism in various forms and shapes (assessments, exam and ITAs)
All these tactic tics are created to wreck non white in the name of training.

Thanks Osceactor for your understanding.
Thanks for reminding me the clause but im surprised u didnt know that the list is freely available on colleges website for anyone to see.
Your comments are definitely insightful
and i hope you are helping people like me around you with your wisdom.
But some of your comments are patronising and your continued defence of college’s ways stinks.

My understanding was that the only stations ever released were those of 2016.1 B. All other stations prior to 2016.1B, and after that, including the subject themes have not been released, and I thought were officially confidential. Thus the clause reminder had your interest at heart, even though you don’t give a ‘f…’ if your anonymity was lost. —-MODERATED—-

Yes, despite being a relatively new FACEM, several candidates seek and value my assistance in their preparation. Please tell me what you found patronising. I agreed with many of your opinions and offered advice on preparation. Your interpretation of my ‘defending the college’ stems from my belief it is not discriminatory on racial appearance.’ That is my honest opinion and I am sorry it doesn’t fit with yours.

Reading these posts , I find it heart wrenching how an examination can be used to determine someone’s worth at the end of an arduous 4 years of advanced training . It has brought back bitter memories that I have since learnt to put aside when I made a conscious decision to not make the fellowship examination a determination of my worth as a doctor . Now the OSCE is merely an inconvenience I have to deal with when I am ready as I have decided for the sake of my family and my sanity , it is just not worth it . Embracing general practice and doing locums has afforded me financial comfort most FACEMs enjoy anyway and life away from acute psychiatric and drug and alcohol affected patients has made me a much better person to be around . I urge the trainees who are failing to realise that there is a very comfortable life away from ED .

I was an angry and broken man after two failed attempts . The college did not give me answers . They never ever wanted to . In fact, a member of the examination committee told me “if we told you exactly what you did wrong , everyone would figure it out and pass ” ( off the record of course ). Well is it not the whole point after 4 agonising years ? The FACEMs I worked with , some concerned , most disinterested, did not really strive to help me or the other failing candidates . Perhaps they didn’t care . More likely , they just didn’t know how to. The college left them in the dark as well.

So here I am a whole year since my last attempt , moving on with life . I was, as many in my circle of ED work colleagues profess , a very industrious and clinically competent doctor . Since failing, I have lost confidence and drive in a practice I once loved .

The bottom line is,the exam process and by extension ACEM has failed us as a group of trainees , regardless of the colour of our skin . I have lost faith in the college and everything it stands for. Now , when a junior doctor asks me if they should pursue ED as a career, I not only say I don’t know anymore , I actively discourage it . A year ago , I would have said “definitely , ED is awesome ” while I lead them to resus to teach them how to reduce a tri-malleolar fracture dislocation of an ankle while frothing at the mouth explaining in detail the mechanical purpose of the syndesmosis. A very sad state of affairs indeed .

As a parting note , to my colleagues who are failing , let it go if you can . Being angry about bias and racism takes away from other options we have in medicine .

To the ones who stay passionate and fight on , thank you for all you efforts . Its going to be a long road .

To the ones who choose to place the blame on the trainees, and not see the deficiencies of a system that fails exam candidates that it was meant to prepare four years prior , just realise if this continues you are just going to end up with a very small cohort of junior registrars coming through the system, higher college fees and also FACEM lead night shifts because all your diligent experienced senior registrars would have either left or would no longer give a shit . Actually , it’s happening now as I write this .